Every finding on record at Minnewaska Community Health Services

Based on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 6 of 6 residents (A24, A25, A27, A33, A35, A36) who currently resided in those rooms.Findings include:During the entrance conference on 4/27/26 at 10:30 a.m., the Director of Nursing (DON) confirmed the rooms in the hallway A did not have at least 100 square feet of useable floor space as required.During the initial screening for residents on the A-wing on 4/27/26 at approximately11:20 a.m., the following resident rooms, A24, A25, A27, A33, A35, A36 were occupied by residents.During an interview on 04/27/2026 at 11:45 a.m., R27 reported the cares provided by staff are not inhibited by the room size.04/28/2026 5:00 p.m., Registered Nurse (RN)-A, reports she is not aware of any complaints from residents due to room size. 04/28/2026 at 5:14 p.m., Administrator-A and Administrator-B both confirmed they had no requests for a room move or complaints of room being too small from any current resident. They also reported they would accommodate any request a resident had regarding more space as allowed. Administration reported that in the past they have moved a resident to a bigger room per family request so the large family could visit at same time. Policy on room size was requested, none was received.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R5) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) In addition, the facility failed to ensure proper hand hygiene was provided to prevent the spread of infection for 1 of 1 residents (R5) observed while receiving wound care.Findings Include:R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and diagnoses which included: dementia, arthritis and psychotic disorder. R5 required assistance with activities of daily living (ADLs) and had one venous ulcer with applications of non-surgical dressings and ointments or medications other than to feet.R5's care plan revised 11/10/25, identified R5 required assistance with bathing, dressing, grooming and transfers. R5 had potential for impaired skin integrity with interventions including monitor wound left foot and follow facility protocol for treatment of skin injury. R5 required enhanced barrier precautions (EBP) related to wounds. Gown and gloves would be worn by staff during high-contact care activities. Signage would be posted notifying staff of needs for EBP. During observation on 11/10/25 at 10:14 a.m., R5 was seated in a wheelchair, dressed in street clothes in the hallway outside her door. R5's room did not have any signage up notifying staff of R5's EBP, and a dresser was at the end of the hallway with PPE supplies in it. R5's room had a normal small trash can, with no trash can placed by exit of doorway. During observation on 11/10/25 at 10:58 a.m., registered nurse (RN)-A knocked, entered R5's room, washed his hands, then applied a mask and gloves. RN-A removed R5's dressings to R5's left foot. R5 had two small open dark areas on top of left foot near her toes, and a large open area on the bottom of her left foot. RN-A then wet a hand towel in the bathroom, applied soap to towel, then washed and dried R5's wounds. RN-A removed gloves, then applied new gloves and applied new dressings to R5's left foot. RN-A removed gloves, then applied gauze wrap, then gripper socks to R5's left foot. RN-A washed his hands, applied gloves, then removed R5's Tubi-grip (compression stocking material) from R5's right leg. RN-A left R5's room for additional supplies, sanitized hands, then returned with washcloths. RN-A applied gloves, wet the washcloth, then washed R5's right leg and foot. RN-A removed gloves, applied new gloves, then applied an antifungal cream to R5's right leg. RN-A removed gloves, then applied new gloves, and put a new Tubi-grip stocking onto R5's right leg. RN-A did not apply a gown prior to R5's wound care as part of EBP. RN-A did not complete hand hygiene after removing gloves and prior to applying new gloves during R5's wound cares.During interview on 11/10/25 at 12:45 p.m., RN-A verified R5 required wound cares and he had applied a mask and gloves prior to wound care for R5. RN-A stated he had worn the mask because of wound care, to prevent spread of infection. RN-A stated he was not required to wear a gown during wound cares. RN-A indicated EBP were for residents who had a catheter or infection in a wound. RN-A then reviewed R5's electronic medical records and verified R5's orders and care plan both identified R5 was on EBP. RN-A indicated he was unaware R5 was on EBP, and stated EBP was important to prevent spread of infections. RN-A indicated usual facility process was to be notified of residents on EBP through report and their care plan. RN-A stated he should have checked R5's care plan prior to wound care. RN-A also indicated the usual facility practice was to put EBP signage up with instructions when residents were on EBP, and was not aware why R5 did not have signage for EBP posted. RN-A also verified he had not completed hand hygiene after removing gloves and prior to applying new gloves during wound care. RN-A indicated he should have sanitized hands between glove use, but there was no hand sanitizer in R5's room. During observation on 11/10/25 at 12:45 p.m., director of nursing (DON) walked in hallway near dining room and was heard telling a nursing assistant to remember purple stars means gowns. Then at 1:02 p.m. DON applied a purple star to R5's nameplate near R5's door, then moved the dresser with PPE from the end of the hall and placed it next to R5's door. During interview on 11/10/25 at 1:12 p.m., DON verified R5 had wounds and was on EBP. DON stated her expectation was gowns and gloves be worn during personal cares and wound cares for R5. DON indicated the facility used purple stars to notify staff residents were on EBP. DON confirmed R5 did not have a purple star up until she applied one that afternoon, and she had put purple stars up and PPE outside other residents' rooms that day who were also on EBP. DON further stated her expectation was that staff complete hand hygiene after remove gloves, prior to applying new gloves to prevent spread of infection. The facility policy titled Enhanced Barrier Precautions, undated, identified EBP was for the prevention of transmission of multidrug resistant organisms. The facility would have the discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP prior to providing high-contact care activities. Gowns and gloves would be available immediately near or outside a resident's room and to ensure alcohol-based hand rub was in every resident room, ideally both inside and outside of the room. Position a trash can inside resident's room and near the exit for discarding PPE after removal. The facility policy titled Hand Hygiene Policy, undated, identified all staff would perform proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors. The policy identified if task required gloves, to perform hand hygiene prior to donning gloves, and immediately after removing gloves. The facility policy titled Clean Dressing Change, undated, identified facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Instructions included to wash hands and put on gloves. After removing the soiled dressing, remove gloves, wash hands and put on clean gloves. Clean wound, measure wound, remove gloves, then wash hands and put on new gloves. Apply ointments or creams, and secure dressing, mark and initial, then dispose of gloves, and wash hands.

Based on interview and document review, the facility failed to implement daily monitoring and assessment of a deep tissue injury ( a type of pressure ulcer, a serious condition that affects the underlying layers of skin, muscle and other soft tissues) for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses which included: diabetes mellitus, cerebral vascular accident (stroke) and anxiety. R1 required partial/moderate assistance with toilet use, hygiene, and substantial/maximal assistance with dressing and transfers. R1 was at risk for pressure ulcers and had no unhealed pressure ulcers. R1's Pressure Ulcer Care Area Assessment (CAA) dated 6/5/25, identified R1 was at risk for potential pressure ulcers and R1's skin was assessed each week by a nurse, and by caregivers with each bath and each time R1 was dressed. Identified interventions were in place to prevent skin break down. R1 would be assisted with repositioning at least every two hours and as needed for comfort. R1's Braden Scale - for Predicting Pressure Ulcer Risk Evaluation dated 6/11/25, identified R1 had a score of 14, which identified R1 was at moderate risk for pressure ulcers. R1's Weekly Wound Round Documentation dated 6/20/25 at 11:21 a.m., identified R1 had a pressure wound acquired 6/20/25. The pressure wound was located on R1's sacrum (area at base of the spine) with length of 6 centimeters (cm), 4 cm width, no depth, and staged as a suspected deep tissue injury. The assessment identified no drainage and surrounding tissue was intact. Current treatment plan was moisture barrier, mattress air overlay and wheelchair/Broda chair (large adjustable cushioned wheel chair) cushion. The assessment identified no pain or odor. R1's care plan revised 6/23/25, identified R1 had a potential for activities of daily living (ADL) self-care performance deficit with interventions which included assistance of one with bathing, bed mobility, dressing, and grooming. R1's care plan identified R1 had limited physical mobility and required Hoyer (mechanical lift) for all transfers. R1 had actual impairment to skin integrity related to mechanical forces, impaired physical mobility, knowledge deficit and impaired circulation/perfusion, as evidenced by (AEB) tissue damage, changes in appearance of the affected area. Interventions included mattress air overlay, required (pressure relieving/reducing mattress, pillows, sheepskin padding etc) to protect the skin while in chair/wheelchair or bed, and weekly documentation. R1's progress notes reviewed 6/1/25 to 7/1/25, identified the following: -6/20/25, at 10:55 a.m., skilled evaluation: R1's skin: 1. The note identified the number one and lacked any further documentation. -6/21/25 at 1:10 a.m., skilled evaluation: R1's skin warm and dry, skin color WNL and turgor is normal. -6/21/25 at 11:33 a.m., skilled evaluation: R1's skin warm and dry, skin color WNL and turgor is normal. Skin issue # 001-identified as: new skin issue, sacrum, type, bruising, unknown how long the wound had been present. Painful yes, no measurements documented as part of the assessment, with reason as not applicable (n/a). -6/22/25 at 6:00 a.m. skilled evaluation: R1's skin issue #001- had not been evaluated. -identified as: new skin issue, sacrum, type, bruising, unknown how long the wound had been present -6/22/25 at 2:06 p.m., skilled evaluation: R1's skin issue #001- had not been evaluated. -identified as: new skin issue, sacrum, type, bruising, unknown how long the wound had been present -6/22/25 at 6:49 p.m., skin check: delegated to night nurse. -6/22/25 at 10:56 p.m., skilled evaluation: -R1's skin issue #001- had not been evaluated. -identified as: new skin issue, sacrum, type, bruising, unknown how long the wound had been present. -6/23/25 at 12:02 p.m. R1 sent to emergency room due to change in level of cognition (LOC) and required oxygen to keep sats over 88%. R1's medical record lacked documentation of daily monitoring of R1's pressure ulcer, including: if pain present, location, staging, size, drainage, description of wound bed, wound edges and surrounding tissue. Review of R1's emergency room attending physician's progress notes dated 6/23/25, identified a severe decubitus ulcer, sacral region unspecified stage. During interview on 6/30/25 at 2:03 p.m., nursing assistant (NA)-A stated NA-A had notified the nurse, case manager and director of nursing (DON) on 6/20/25, that R1 had a dark bruise area on her sacral area, and DON assessed it. During interview on 7/1/25 at 8:16 a.m., registered nurse (RN)-A stated RN-A had become aware of R1's deep tissue injury on 6/20/25, and notified DON. RN-A confirmed she had sent R1 to the emergency room on 6/23/25, and had not observed or assessed R1's pressure ulcer. RN-A said her usual practice for when to monitor pressure ulcers, was when completing dressing changes, or to check to assure the dressings were intact. RN-A stated DON completed all other wound assessments weekly as the wound nurse. During interview on 7/1/25 at 8:45 a.m., DON stated she was the facility wound nurse. DON confirmed she had been informed by the nursing staff on 6/20/25, that R1 had an darkened area on sacrum. DON reviewed R1's progress notes with skin assessments, and indicated she was not aware why some of the assessments were identified as no skin issues, or not evaluated. In addition, DON indicated she did not know what the number one represented in the skin progress notes listed above. DON indicated her expectation was that staff assessed pressure ulcers daily or every shift when competing skilled nursing assessments. During a telephone interview on 7/1/25 at 10:36 a.m. , RN-B indicated he thought he evaluated R1's deep tissue injury when observing R1 while she was in bed. RN-B was unable to describe the wound however, thought it looked kind of blackish, was not open and stated he could not remember for certain. RN-B stated there were no orders to observe R1's wound or any treatment plan. During a telephone interview on 7/1/25 at 11:37 a.m., RN-C indicated RN-C had been aware of R1's pressure ulcer and had documented it in R1's skills assessment and stated there was a place to check if there was no change. RN-C stated when RN-C had viewed R1's pressure ulcer, it was intact. During a telephone interview on 7/1/25 at 11:45 a.m. licensed practical nurse (LPN)-A indicated LPN-A had not been aware R1 had a pressure ulcer, until after R1 had been sent to the hospital. LPN-A stated R1 did not have any orders on her treatment administration record (TAR) to assess or treat a pressure ulcer. During a follow up interview on 7/1/25 at 11:29 a.m., DON indicated if a resident was receiving skilled services, the nurses were expected to assess the resident's skin each shift on the resident's skilled evaluation. DON stated if a long term resident had a pressure ulcer, she would place a nursing order in the electronic health record for nurses to assess the pressure ulcer daily. Review of the facility policy Pressure Injury Prevention And Management Policy dated 1/1/25, identified licensed nurses would conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings would be documented in the medical record. The policy identified monitoring would be completed by weekly wound assessments until resolved. The facility policy lacked identification of required daily monitoring of pressure ulcers.

Based on interview and record review the facility failed to ensure dignified and respectful services for 4 of 6 residents (R2, R3, R4, R5) reviewed who reported concerns related to staff treatment. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], identified she had moderately impaired cognition and disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject) that fluctuated and changed in severity two out of seven days of the week. She had impaired range of motion (ROM) upper extremity on one side and bilaterally lower extremities. She required substantial/maximal assistance with upper and lower body dressing, personal hygiene and dependent upon staff for shower/bathing, toileting, roll left and right, sit to lying, lying to sitting, all transfers, and mobility. She was always incontinent of bowel and bladder. Medical diagnoses included: peripheral vascular disease (PVD) (arteries or veins become narrowed or blocked, reducing blood flow to the limbs, typically in the legs), arthritis, osteoporosis, dementia, hemiplegia/hemiparesis (a neurological condition that affects causing weakness or paralysis on one side of the body), seizure disorder/epilepsy, anxiety, and macular degeneration (an eye disease that can blur your central vision). R2's care plan dated 3/18/25, identified a self-care performance deficit and directed staff to transfer her with a Hoyer lift with assist of two staff, provide all ADLs, and turn and reposition in bed. She was at risk for impaired skin integrity and directed staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. During an interview on 3/27/25 at 11:24 a.m. R2 stated she had polio when she was two years old which resulted in no neck muscles and found it uncomfortable when she sat in the wheelchair. Staff hooked her up to the harness (lift sheet) to Hoyer lift, left the room, closed the door, and looked for assistance to transfer her. She stated it made her feel like a horse with a harness and had asked staff to wait until both staff arrived prior to when she was hooked up. Staff rushed when they used the Hoyer lift, had forgotten to move her legs/feet out of the way, pinched and bumped them when staff pushed the emergency button on the lift machine and lowered her down quickly. While staff positioned her to be transferred from bed to wheelchair today, she was instructed to place her hands on her chest and hold her head up. She reminded staff to be careful of her feet, while staff pulled the emergency lever on the Hoyer lever and lowered her down quickly into the wheelchair. She was afraid her head would be hit by the Hoyer lift bar that hung over her head. She had been knocked in the head more than once by the Hoyer bar while she was lowered too quickly. On another occasion she was lowered into the wheelchair and the loop on the lift sheet had hit her in the eye. Staff had pulled her shirt off quickly and her right arm hurt. Her daughter called DON and was told she would talk to staff. She also reported this to the director of nursing (DON) and was told she would talk to the staff. She felt safe but uncomfortable with staff and frustrated when she reported concerns, and no changes noted. She identified a nursing assistant (NA)-A that was not her favorite. NA-A handled her roughly and worked fast, always in a hurry, never hurt her but she had screamed and yelled when her right arm was not handled gently, no bruises or injuries thank goodness. She was able to assist when staff requested her to turn to her right side, grabbed the bed railing, but was not allowed the time, and turned quickly by NA-A. She had cried more than once, felt disrespected, did not feel like home to her, and wanted to move out of facility. NA-A had continued to use the emergency button on the Hoyer lift and reported how she was treated by NA-A to the DON and planned to talk with DON again today. She stated she felt staff could treat her better and with respect. R3's quarterly MDS dated [DATE], identified intact cognition with no behaviors. She required substantial/maximal assistance with upper and lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sit, sit to stand, and all transfers, dependent on staff for toileting hygiene and bathing/shower. She was unable to ambulate. She was always incontinent of bowel and bladder. Medical Diagnoses included: cancer, congestive heart failure, diabetes mellitus (DM), anxiety, obesity, and depression. R3's care plan dated 3/19/25 identified ADL self-care performance deficit and directed staff to establish a routine to provide a sense of security and confidence with resident, provide moderate assistance of one with bathing, bed mobility, incontinent brief changes, anticipate needs, and transfer with assist of two and sit to stand lift. Allow resident to accomplish tasks at her own pace, do not hurry them, and encourage independence only when resident was able to safely do so. She had potential for impaired skin integrity. Staff were directed to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. She was prescribed an anticoagulant and staff were directed to protect resident from injury and trauma. During an interview on 3/27/25 at 10:13 a.m. R3 stated staff transferred her with a stand lift. She was concerned about her tender feet when taken to the shower by NA-A. She was placed into the shower/tub, feet first, her feet had gotten bumped into the inside to the tub and was painful. She no longer allowed NA-A to take her to the tub anymore. NA-A was rough with how she handled her, reported to management, was told no one else complained about her, and nothing was done. She allowed NA-A to transfer her with the stand life in her room only but watched where her feet were placed so that they did not get jammed somewhere. She stated she felt safe because she was able to speak up for herself but worried about those residents that were unable to say anything. NA-A had informed her not to tell her how to do her job when she encouraged her to slow down, watch her feet, and adjust incontinent brief when not placed properly. Her stools were horrible, runny, and when NA-A rushed while she placed the brief on improperly caused a mess in the bed, which not only caused quite the smell but embarrassment. NA-A told her she should spend some of her money on something to help the stool smell in her room. R4's quarterly MDS dated [DATE], identified intact cognition without behaviors. She had impairment ROM bilaterally upper and lower extremities. She required substantial/maximum assistance with oral hygiene, upper body dressing, personal hygiene, roll left and right, and dependent for all transfers, sit to lying, lying to sit, unable to walk, and used a motorized wheelchair for mobility. She had an indwelling catheter and frequently incontinent of bowel. Her diagnoses included: quadriplegic (a condition characterized by partial or complete paralysis of all four limbs, arms, and legs), depression, and anxiety. R4's care plan dated 3/24/25, identified she had an ADL self-care performance deficit and directed staff to allow sufficient time and assistance for her to dress and undress, she required assistance of two staff and a mechanical lift to transfer, and anticipate her needs. She had potential impairment to skin integrity of the coccyx related to quadriplegia. Staff were directed to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. During an interview on 3/28/25 at 12:53 p.m. R4 stated the care at the facility was sometimes questionable. Staff rushed too much, lacked taking the time needed to complete tasks properly. Her catheter strap was located on the side of the leg and pants were not pulled up straight, later she had pressure marks on her leg. Staff failed to recognize the lift sheet was pulled up too tight between her legs during a transfer with the transfer lift and resulted in red marks in the groin area. She had not felt safe during a few of the total lift transfers especially on Tuesday when the lift sheet was placed too low on her hips and she had to be placed back on the bed crosswise during the transfer. She became anxious when things were not positioned correctly when she drove and when she had a spasm could have caused an accident. She preferred staff used the soaker sheet when they turned onto her side so that they avoided pulling /pushing on her. She was able to turn herself if only the staff would have slowed down an allowed her help. NA-A frequently used the emergency button on the total body lift machine, showed other staff how it was to be used, felt worse when she did, too fast and resulted in a bumped shoulder on the lift bar. NA-A had placed her in the shower chair, rushed too much, and bumped her feet. NA-A told her, another resident along with her should have not been placed in the same hallway, could not spend that much time helping us. There were a few other staff that had told her it had taken too long to take care of her. Those types of comments/actions of staff did not make her feel very well. She felt she was time consuming, angry, and irritated. She stated she told staff when they were rough with her during cares that hurt, to knock it off. She was in this facility because she required help and unable to live at home and independent once the staff assisted her up out of bed in the morning and completed cares. She had told a staff NA about her concerns and felt comfortable talking to only certain staff about her concerns. R5's quarterly MDS 12/27/24, identified intact cognition with no behaviors. She had impaired bilateral lower extremities range of motion (ROM). She required substantial/maximal assistance with roll left and right, dependent on staff to provide oral/toileting/personal hygiene, shower/bathing, upper and lower dressing, sit to lying, lying to sitting, sit to stand, and all transfers. She was unable to ambulate and used a motorized wheelchair for mobility. She was occasionally incontinent of bowel and always incontinent of bladder. Her diagnoses included: CHF, DM, and arthritis. During an interview on 3/27/25 at 9:27 a.m. R5 stated NA-A was a little rough with her approach when she cared for her. She was unable to turn herself in bed, NA]-A was stronger than the rest of the staff and without warning would be pushed over to her side rather fast and was unexpected. NA-A was the only staff that rushed through cares, and she had not reported anything. She was a bigger resident than most and did not feel it was intentional but when she talked with other residents, they did feel it was. NA-A used the emergency button on the Hoyer lift when she transferred her. NA-A usually waited until her bottom was on the bed or until her wheelchair was reclined, braced herself and then the emergency button would be pushed. There were times when her back was not placed down on the bed, approximately four inches away and NA-A pushed the emergency button on the Hoyer lift, and she felt a jolt. During an interview on 3/26/25 at 3:44 p.m. licensed practical nurse LPN-(A) stated on 3/24/25, she reported to the DON possible concerns she had regarding NA-A cares provided and transfer with a total lift machine. Later that same day, NA-B reported to her NA-A moved fast when she completed cares and transfers, used the emergency button on the total lift machine so that multiple residents were lowered down quickly into the chair and/or bed. She did not report that information and should have. During an observation on 3/26/25 at 4:45 p.m. NA-A and NA-B entered R2's room with a lift machine. R2 laid in bed on her back. Both NA's applied gloves and explained she would be transferred to her wheelchair for supper. Lift sheet, dark blue with green trim, was placed underneath her by rolling her slowly from side to side. Head of bed (HOB) was raised, and shoes applied. NA-A placed the loops of the lift sheet onto the lift machine and lifted her up off the bed with the remote control. NA-A moved the lift machine over to the wheelchair and slowly lowered her down onto the wheelchair. The emergency button was not used. NA-A and NA-B removed the lift sheet loops from the lift machine, tucked the lift sheet into the sides of her wheelchair and underneath her thighs, removed gloves, and sanitized their hands. During an interview on 3/26/25 at 4:56 p.m. NA-A stated the lift machine had an emergency button used to lower residents down quickly. She had used the emergency button once while she transferred a resident, and the battery was almost drained. She had not used the emergency button during a transfer since. Staff were educated the emergency button should have not been used for regular transfers or when a resident was in the lift. A resident would not get injured if the emergency button were used and lowered too quickly. She treated residents well, provided cares efficiently, and safely. She had not witnessed any staff treat residents in a poor manner or received any complaints from residents. The DON interviewed her on 3/25/25, regarding transfers and cares completed on 3/24/25. During an interview on 3/26/25 at 5:20 p.m. LPN-B stated he had assisted NA's with transfers with the total lift machine. He had been informed by staff NA-A had been rough with R3. He talked to R3, and she told him NA-A was not the most gentle touch, seemed to feel it was not too terribly rough, and no other comments. He had not received any other complaints about NA-A and was that information was not reported. During an interview on 3/27/25 at 10:47 a.m. NA-D stated the emergency button on the total lift machine was to be used only during an emergency. She had completed total lift machine transfers with NA-A and encouraged by NA-A to use the emergency button during the transfers especially on those residents that were heavier, so they were lowered down faster. The emergency button on the total lift machine was hard to pull. She was instructed by NA-A on how to emergency button should have been used and when she did it jerked the resident while they remained in the lift sling. She had not witnessed a resident hurt by this process but when used frequently could have possibly caused an injury. She had noticed since 2/19/25, NA-A worked fast and there were three residents that had informed her NA-A provided rough care. R3 informed her NA-A bumped her feet during transfers and refused to allow her to transfer or be pushed around by her anymore. R2 informed her during transfers had bumped her head with the lift machine bar, feet, and lowered quickly down into the bed or wheelchair. She was not sure if that was unusual, staff worked at different paces. R4 had told her staff rushed through cares, flipped over onto her side too fast, was not allowed time to assist with turns when able to, and felt frustrated and disrespected. The complaints were not reported but realized now she should have said something. During an interview on 3/27/25 at 12:10 p.m. NA-B stated NA-A was rough with the residents, very strong, and completed tasks quickly without thinking. She had told NA-A to slow down, it was not a race and would prevent injury to the residents. During repositioning or when a resident was turned NA-A used her hands, pushed on the wrong spot on the body they maybe sore already, and turned them quickly, causing more pain. She had seen NA-A transfer residents, without paying attention to the location of their feet and their head and they have gotten bumped. She had completed total lift machine transfers with NA-A and witnessed her rushing through the transfer placing the resident's safety at risk. She received complaints from residents R4, and R2, NA-A was rough and flipped them over too fast during cares. She has not witnessed any bruises or injuries. She had talked to LPN-A regarding her and resident concerns and encouraged residents to report concerns to the nurse on duty or the DON. The emergency button on the total lift machine was to be used only in an emergency, not daily. The facility had some heavier residents, was unsafe to be dropped down fast and could have possibility been injured. She had informed staff if they did not like working with old people, treated them poorly, they should have looked for a different job and would be reported. During an interview on 3/27/25 at 2:46 p.m. NA-C stated she had noticed there were staff NA's were rough with residents when moved or repositioned with their hands instead of using the soaker pads. She witnessed R3 requested to be boosted up in bed and NA-D replied, no. She was in a resident's room and heard NA-A stated in front of the resident how annoyed she was when the resident used the bed remote and placed her bed up and down frequently, cord pulled out of the wall, happened every night, had to get down on the floor, and plugged it back in. Had not reported concerns right away and on 3/25/25, in the afternoon she reported her concerns to DON. During an interview on 3/28/25 at 10:04 a.m. DON stated she was not aware of any concerns with residents being treated inappropriately by staff. R2 complained about her wheelchair and was looking for another place to move to. R2's daughter had not contacted her regarding concerns on how she was being treated at the facility. On 3/24/25 she had interviewed five residents all located on the same wing in the facility. Those residents were asked how they were doing, any concerns, and all said things were fine. She stated the residents would have told her if something had bothered them. During an interview on 3/28/25 at 12:15 p.m. administrator stated she was unaware of any resident concerns treated inappropriately by staff. We have great policies, need to be followed, and concerns would be expected to be reported right away. When concerns were identified interviews were expected to be completed with all residents in the facility. She had not received any complaints from staff or residents regarding staff. On 3/27/25, DON informed her about concerns and lack of staff reporting. Staff were terminated on 3/27/25. Facility policy Promoting Maintaining Resident Dignity undated identified it was the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains resident's quality of life by recognizing each resident's individuality. Staff were expected to explain care or procedures before initiating the activity and speak respectfully to residents.

Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the resident's current wishes which affected 1 of 30 residents (R9) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R9 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R9's electronic health record (EHR) banner and orders identified R9 was to have CPR however, R9's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R9's wishes of do not resuscitate (DNR). The administrator, assistant administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:49 p.m. The IJ was removed on [DATE], at 11:35 a.m.,when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively impaired and had diagnoses which included dementia, asthma, and hypertension (elevated blood pressure). Identified R9 was dependent on staff for activities of daily living (ADLs) which included bed mobility, toileting, and transfers. R9's current POLST signed by family member (FM)-A on [DATE], identified R9's wishes were DNR. The POLST was scanned into her EHR and signed by her medical provider on [DATE]. Review of R9's current EHR Order Summary Report signed by her medical provider on [DATE], identified R9 had an order for CPR even though R9's POLST identified DNR. Review of R9's EHR banner on [DATE] at 1:12 p.m., identified R9 wanted CPR. Review of R9's face sheet in the EHR undated identified R9 was admitted to the facility on [DATE]. Identified R9 wanted CPR. R9's care plan revised [DATE], identified R9 wanted CPR. Identified the POLST would be reviewed quarterly and as needed. Review of a facility report sheet dated [DATE] -[DATE], located at the nurses station identified R9 wanted CPR. During an interview on [DATE] at 2:39 p.m., FM-A stated she had signed the POLST on [DATE], stating that R9's wishes were to be DNR. During an interview on [DATE] at 4:19 p.m., licensed practical nurse (LPN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the EHR banner and would have proceeded accordingly. LPN-A verified R9's banner identified R9 wanted CPR. LPN-A verified there was was a discrepancy between R9's banner and the POLST. During an interview on [DATE] at 4:22 p.m., registered nurse (RN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the report sheet located at the nurses station and would have proceeded accordingly. RN-A verified R9's report sheet identified R9 wanted CPR. RN-A verified there was a discrepancy between R9's report sheet and the POLST. During an interview on [DATE] at 4:24 p.m., RN-B indicated in the event a resident did not have a pulse or respirations, he would refer to the EHR banner and would have proceeded accordingly. RN-B verified R9's banner identified R9 wanted CPR. RN-B verified there was a discrepancy between R9's banner and the POLST. During a joint interview on [DATE] at 4:41 p.m., assistant director of nursing (ADON) and DON stated upon admission, all residents were assigned a full code (CPR) status. ADON and DON stated a POLST was then completed with all residents or resident representatives and sent off to the provider for a signature. ADON and DON confirmed there was a discrepancy with R9's banner and current physician orders which identified R9 was a full code and did not match her current wishes of being DNR. ADON and DON confirmed in the event R9 did not have a pulse or respirations, CPR would have been initiated against R9's wishes. DON indicated she would expect staff to follow the POLST, resident wishes and the facility policy. Review of a facility policy titled Code Status Policy revised [DATE], identified the facility would follow a policy regarding a resident's right to request, refuse, and/or discontinue medical treatment and to formulate an advance directive. Identified the POLST would have been documented in the EHR. Further identified the code status would have been reviewed with Care Conferences at least quarterly and documented in the medical record. The IJ was removed on [DATE] at 11:35 a.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form, the electronic medical records were updated to ensure resident's wishes for advance directives, were accurate on [DATE]. -R9's EHR record was updated to match the current POLST. -All current licensed staff were educated on the policy for advance directives, updating the POLST and the EHR to reflect the resident's wishes on [DATE], as evidenced by the education sign in sheet and interviews. -A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift on [DATE], by notification of required education via phone/text. All staff would sign off once education had been completed. -The advance directive policy was reviewed and determined no changes were required.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 30 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified excessively low weekend staffing. During an interview on 3/23/25 at 12:45 p.m., administrator confirmed the above findings and stated the low weekend staffing always happened because contracted staff hours had not been calculated into the system before it was submitted to CMS. Administrator further stated the PBJ would continue to be incorrect because the contracted staff hours would not be received on time from the contract company to accurately submit the facility's information to CMS. During an interview on 3/25/25 at 2:22 p.m., the administrator and chief financial officer (CFO) stated contracted staff hours were gathered from the invoices the facility received from the contract company. CFO further stated the invoices were received after the required submission date of the facilities PBJ information to CMS. CFO indicated contracted staff hours would continue to not be included in the PBJ due to the dates of the invoices and the required submission time of the facility's PBJ information to CMS. Review of facility policy titled Payroll Based Journal undated, It was the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on observation, interview and document review, the facility failed to establish an on-going infection control program which included comprehensive surveillance of resident infections. In addition, the facility failed to ensure hand hygiene was completed for 6 of 30 residents (R7,R10, R14, R22, R28, R31) observed during the afternoon water pitchers being delivered. These deficient practices had the potential to affect all 30 residents who resided in the facility. Findings include: SURVEILLANCE A review of the facility's infection control surveillance log titled Peerlytics dated October - December 2024 and January - March 2025, revealed the following: -Facility map included resident's room number and the resident's room was highlighted if the resident had a diagnosed infection. - The facility's current surveillance log lacked tracking necessary data which included: signs and symptoms for each infection, dates cultures were obtained, when the antibiotic was completed, when the antibiotic was discontinued, and when symptoms resolved. During an interview on 3/24/25 at 4:39 p.m., director of nursing (DON) and assistant director of nursing (ADON) indicated the facility used Peerlytics infection map to track resident's with diagnosed infections. DON and ADON stated the mapping document only included illnesses that were diagnosed and did not track signs and symptoms, culture results, or the antibiotic being used. 49620 HAND HYGIENE DURING WATER PITCHER PAS During an observation on 3/24/25 at 2:30 p.m., nursing assistant (NA)-B and NA-C pushed a cart of water pitchers from C-wing to A-wing. NA-B entered R7's room with a water pitcher from the cart and removed the used water pitcher from R7's room and placed on the middle shelf of the cart. NA-C entered R28's room with a water pitcher from the cart and removed the used water pitcher from R28's room and placed on the middle shelf of the cart. NA-B repeated the process for R10 and R14. NA-C repeated the process for R31 and R22. Three staff and two residents were observed to walk past the water pitcher cart. NA-B and NA-C did not sanitize their hands prior to entering a resident room or after touching the used water pitchers. During a joint interview on 3/24/25 at 2:35 p.m., NA-B and NA-C confirmed they did not sanitize their hands during the entire water pitcher delivery service. Both NA-B and NA-C stated they should have sanitized their hands to prevent the spread of infection. During an interview on 3/24/25 at 4:31 p.m., assistant director of nursing (ADON) verified the expectation of staff would be to sanitize their hands in between the new and used water pitchers being delivered to prevent the spread of germs and possible illness to the residents. During a follow up interview on 3/24/25 at 5:36 p.m., DON and ADON confirmed the facility did not have a process for tracking and trending infections within the facility. DON and ADON further confirmed the mapping only showed current resident infections. DON and ADON indicated they were unaware all signs and symptoms needed to be tracked for every resident. DON and ADON further indicated the facility had not had an outbreak therefore there would have not been a need to track signs or symptoms for every resident. During a follow-up interview on 3/25/25 at 2:06 p.m., DON and registered nurse (RN)-A provided spreadsheets for tracking and trending of residents infections for October - December 2024 and January - March 2025. DON and RN-A stated the spreadsheets were filled out the night before. DON further stated the spreadsheets should have been used before for tracking and trending. During an interview on 3/25/25 at 2:17 p.m., administrator confirmed the above findings and indicated she was unaware tracking and trending was not being completed. Administrator stated her expectations were trending and tracking of residents signs and symptoms of an infection were completed. Administrator further stated she would expect staff to completed contract tracing and utilize the facility software to help reduce/prevent an illness outbreak in the facility. Administrator indicated tracking and trending of infections was important to keep residents safe and healthy. Facility policy on infection control surveillance was requested, however one was not provided. A facility policy titled Hand Hygiene, undated, identified all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene would be performed after handling contaminated objects.

Based on observation, interview and document review, food was not served in a sanitary manner for 30 residents who dined in the dining area observed during dining services and who received an afternoon snack. In addition, the facility failed to maintain the ice machine and the coffee machine in a sanitary manner to prevent potential illness for 30 residents who currently received ice from the ice machine and or coffee from the coffee machine in the dining area. Further, the facility failed to maintain proper holding food temperatures for cole slaw that was to be served during the evening meal for all residents in the dining room. These deficient practices had the potential to affect all 30 residents residing in the facility. Findings include: FOOD SERVICE During an observation on 3/23/25 at 11:51 a.m., activities aide (AD)-A was serving beverages in the dining room. AD-A was not observed to wash her hands and was not wearing gloves. AD-A picked up a glass off the table holding the top rim with her fingers, poured tomato juice into the glass and placed the glass on the table. AD-A picked up another glass holding the top rim with her fingers and poured water. AD-A picked up a coffee cup holding the top rim with her fingers and carried the cup over to the hot water for tea. AD-A then placed a clothing protector around a resident's neck and touched the resident's skin while closing the snaps on the back of the clothing protector around the residents neck. AD-A proceeded to pick up a glass holding the top rim with her fingers and poured milk. AD-A picked up three prefilled thickened glasses off of the beverage cart of milk and two juices. AD-A removed the plastic wrap off of the top rim of the three glasses with her fingers, held onto the top rim and placed each glass on the table. During an interview on 3/23/25 at 12:52 p.m., AD-A stated she usually poured the beverages at lunch time. AD-A confirmed she picked up the glasses and coffee cup holding the top rim with her fingers. AD-A stated she had not received any specific training on handling glasses and did not perceive handling the top rim of the glasses as a concern. During an observation on 3/23/25 at 2:28 p.m., AD-A had a food cart in the A-wing with individual desserts and beverages. AD-A was visiting with a resident who was in a wheelchair sitting at an even height of the desserts directly next to the food cart. The desserts were observed to be uncovered and individual plastic wrap pieces stacked up sitting next to the tray of desserts. Two staff members were observed to walk past the food cart while AD-A was visiting with the resident. AD-A confirmed the desserts were not covered and she removed the plastic wrap in the kitchen from each dessert prior to bringing the food cart down the hall as it was quicker to serve the desserts. AD-A did not perceive the desserts being uncovered as a concern. During an interview on 3/24/25 at 4:31 p.m., assistant director of nursing (ADON) stated the activities staff usually assisted in the dining room and delivered afternoon snacks. ADON was unaware of any specific training the activities staff received on handling glasses or delivering food. ADON confirmed the expectation of staff was to handle the bottom of a glass while serving beverages and not touching the top rim of the glass as the glass would be contaminated with germs and a resident could become ill. ADON further confirmed desserts should be covered while the food cart goes down each hall to prevent germs from others getting on the food and potentially causing foodborne illness to the residents. ICE MACHINE During an observation on 3/23/25 at 11:37 a.m., the hot water spout on the coffee machine in the dining room had a white powder substance build up around the entire spout. In addition, the ice machine in the dining room had a white scaley substance build up around the entire inside of the spout approximately one to two inches in height. During an interview on 3/25/25 at 10:44 a.m., dietary manager (DM) verified the hot water spout on the coffee machine had a white powder substance build up around the entire spout and the ice machine had a white scaley substance build up around the entire inside of the spout. DM stated dietary staff were expected to clean the coffee machine at the end of each evening shift. DM was unaware of any staff cleaning the ice machine. DM stated there was not a log for cleaning the machines. DM verified the white substances could have bacteria present and residents could develop illness as a result. During an interview on 3/25/25 at 10:47 a.m., maintenance director stated he was unaware of cleaning logs for the coffee machine and ice machine and dietary staff were expected to clean them. The maintenance director stated he had not been notified of any white substance build up on the coffee machine or the ice machine. FOOD TEMPERATURE During an observation and interview on 3/24/25 at 12:04 p.m., dietary aide (DA)-A was temping food at the steam table in the dining room. Another dietary aide was writing the food temperatures onto a piece of scratch paper. A large uncovered plastic bin of cole slaw was sitting on the counter next to the steam table. DA-A temped the cole slaw after the hot foods at 12:14 p.m., at 49.5 degrees Fahrenheit (F). DA-A starting to serve the meal and was stopped by surveyor and asked what the cold food holding temperature was supposed to be. DA-A stated she was unaware what the cold food holding temperature should be and asked the dietary manager standing behind her. DM stated the cold food holding temperature should be between 40 and 45 degrees F. DM then removed the cole slaw from the meal service. During a follow up interview on 3/24/25 at 4:10 p.m., DA-A stated temperatures were written on a piece of paper and later transferred to the three ring binder of food temp logs. The food temp logs were observed to have breakfast, noon meal and evening meal entries with the recommended temperature of each food group listed. DA-A stated she was unable to verify food temperatures without use of the log. During an interview on 3/24/25 at 4:17 p.m., DM confirmed the cole slaw was at 49.5 degrees F and was unaware cold food holding temperature was 41 degrees F or less. DM verified the food temperature logs state salad 40 to 45 degrees for cold food temperature and that dietary staff usually wrote the temperatures on a piece of paper and transfer to the log book after a meal service. DM stated there was not a policy or procedure for keeping foods cold. DM stated the expectation was dietary staff to know the proper holding food temperatures to prevent the residents from developing food borne illness. The Food and Drug Administration food code identified the danger zone refers to the range of temperatures at which bacteria can grow between 40 degrees Fahrenheit (F) and 140 degrees F. For food safety, keep food below or above the danger zone. A facility policy titled Food Safety Requirements, undated, identified food distribution included holding foods hot on the steam table or under refrigeration for cold temperature control. When meals were assembled in the kitchen and then delivered to resident rooms, covering foods was appropriate, either individually or in a mobile food cart. Food would be covered when traveling a distance (i.e., down a hallway, to a different unit or floor). Food service safety referred to handling, preparing, and storing food in ways that prevent foodborne illness. Foodborne illness referred to an illness caused by the ingestion of contaminated food or beverages. Staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures were maintained. Staff shall refer to the current Food and Drug Administration (FDA) Food Code and facility policy for food temperatures as needed. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. A facility policy for the coffee machine was requested and not received. A facility policy titled Ice Machine Policy and Procedure reviewed 10/26/19, identified the ice machine would be washed and wiped down daily at the end of each evening shift, making sure that the storage bin drains were clear and no Lime build up had occurred. If there was lime build up to notify maintenance for descaling. A manufacturer form provided by the facility titled Manitowoc Nugget Ice Machine dated July 2022, identified over time the drip tray and cup rest/spouts may become coated with scale or dirt. They could be removed and scrubbed in a sink. The spouts/chutes and drip tray were to be washed and to use ice machine scale remover if needed to dissolve scale. Recommended cleaning the ice machine every six months and more frequent cleanings may be required based on the mineral content of the water, run time and potential airborne contamination.

Based on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 10 of 10 residents (R7, R10, R14, R16, R22, R23, R25, R27, R28, R31) who currently resided in those rooms. Findings include: During the entrance conference on 3/23/25, the administrator confirmed the rooms in the hallway A did not have at least 100 square feet of useable floor space as required. During the initial screening for residents on the A-wing on 3/23/25 at 12:15 p.m., the following resident rooms for R7, R10, R14, R16, R22, R23, R25, R27, R28, R31 were observed to not have at least 100 square feet of useable floor space as required. On 3/23/25 at 2:13 p.m., R14 stated she would like a bigger room when one became available but was happy with her room and had no concerns. -at 2:20 p.m., R16 rested in bed, unable to respond to a question regarding room size. -at 2:22 p.m., R25 rested in bed, unable to respond to a question regarding room size. -at 2:25 p.m., R22 stated the room was big enough for him. -at 2:40 p.m., R31 rested in bed, unable to respond to a question regarding room size. -at 2:43 p.m. R7 stated the room was big enough for her. -at 2:45 p.m., R27 stated the room was big enough for him. -at 2:50 p.m., R10 rested in bed, unable to respond to a question regarding room size. On 3/24/25 at 2:33 p.m., R23 stated the room was big enough for him. -at 2:38 p.m., R28 rested in bed, unable to respond to a question regarding room size. R28's daughter stated no concerns with the room size. The following rooms on the A-wing were unoccupied A-30, A-33 and A-34. During an interview on 3/23/25 at 2:30 p.m., nursing assistant (NA)-B stated no residents had complained about the size of their rooms. During an interview on 3/24/25 at 2:35 p.m., maintenance director provided room measurements with surveyor. Maintenance director stated the rooms are less than 100 feet. During an interview on 3/25/25 at 10:13 a.m., director of nursing (DON) stated the facility would move a resident if they were not satisfied with their room. Director of nursing had not heard of any complaints about room sizes. During an interview on 3/25/25 at 10:18 a.m., administrator stated the rooms on the A-wing measured between 95.68 and 96.07 square feet. The administrator planned to apply for a waiver. A facility policy was requested and not received.

Based on observation, interview and document review, the facility failed to ensure cleaning chemicals were secured away in a locked cabinet or cart, which had the potential to affect all residents residing on the B-wing (8 rooms - B-39, B-40, B-41, B-42, B-43, B-44, B-45, B-46). Additionally, it had the potential to affect 2 of 30 (R22 and R10) who were observed walking down the hallway. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 was severely cognitively impaired and had diagnoses which included dementia, traumatic brain injury (TBI) and alcohol dependence. Identified R22 was independent with transfers and mobility. R22's care plan revised 3/23/25, identified R22 had wandering behaviors. R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 was severely cognitively impaired and had diagnoses which included dementia, depression, and glaucoma (difficulty with vision). Identified R10 was independent with transfers and mobility. R10's care plan revised 3/6/25, identified R10 had wandering behaviors. During observations the following was observed: -3/23/25 at 11:45 a.m., the tub/shower room door was propped open with the white trash can. Sitting to the right of the tub on the floor were two full bottles of vindicator+ (disinfectant/cleaner) one with no cap and the other closed with a cap. Sitting on the green rolling cart with hygiene supplies was one bottle of QT-TB (disinfectant/cleaner) 3/4 full in a spray bottle. Sitting on the tan rolling cart with hygiene supplies was a one bottle of Quarternary (Barrier II) based sanitizer 3/4 full in a spray bottle. The storage room B-50's door was open and one full bottle of pine liquid odor control was sitting on the floor in front of the wooden toiletry shelf. No staff were present down the hallway or ar the nurses' station. -3/23/25 at 2:10 p.m., both doors remained open and chemicals remained in the same place. -3/24/25 at 8:38 a.m., tub/shower room door continued to be propped open with the white trash can. Sitting to the right of the tub on the floor was one full bottle of vindicator+ and one empty bottle. Sitting on the white wire shelf above the tan rolling care was one bottle of QT-TB 3/4 full. The storage room B-50's door was open and one full bottle of pine liquid odor control was sitting on the floor in front of the wooden toiletry shelf. No staff were present down the hallway or ar the nurses station. -3/24/25 at 11:11 a.m., both doors remained open and chemicals remained in the same place. R22 walked down the hallway past both open doors to the exit. R22 remained at the exit door for approximately two minutes and walked back down the hallway past both open doors to another part of the facility. -3/24/25 at 1:39 p.m., both doors remained open and chemicals remained in the same place. -3/24/25 at 1:48 p.m., both doors remained open and chemicals remained in the same place. Nursing staff left the B-wing. - 3/25/25 at 7:25 a.m., tub/shower room door continued to be propped open with the white trash can. Sitting to the right of the tub on the floor was one full bottle of vindicator+ and one empty bottle. Sitting on the white wire shelf above the tan rolling care was one bottle of QT-TB 3/4 full. The storage room B-50's door was open and one full bottle of pine liquid odor control was sitting on the floor in front of the wooden toiletry shelf. No staff were present down the hallway or ar the nurses station. -3/25/25 at 12:56 p.m., both doors remained open and chemicals remained in the same place. R10 wheeled in R10's wheelchair down the hallway past both open doors to the exit door. R10 remained at the exit door for approximately five minutes. R10 wheeled R10's wheelchair back down the hallway past both open doors to another area in the facility. -3/25/25 at 1:12 p.m., both doors remained open and chemicals remained in the same place. R22 walked down the hallway past both open doors to the exit. R22 remained at the exit door for approximately two minutes and walked back down the hallway past both open doors to another part of the facility. During an interview on 3/25/25 at 1:20 p.m., nursing assistant (NA)-A stated nursing staff cleaned and disinfected the tub after a resident had received a bath and before another resident would enter the tub. NA-A indicated both doors were to be shut after staff were finished cleaning and disinfecting the tub or getting supplies out of the storage area. When NA-A was finished talking with surveyor, NA-A left the B-wing and both doors remained open. During an interview on 3/25/25 at 1:55 p.m., director of nursing (DON) confirmed the above findings and stated the doors to both rooms were to be closed at all times. DON indicated neither room had a lock on the door and chemicals were not locked in a storage area. DON further indicated even if the doors were closed the chemicals would not be stored properly. DON stated having chemicals sitting out could have the potential for a harmful situation. During an interview on 3/25/25 at 2:14 p.m. administrator confirmed the above findings and stated her expectations were chemicals were to be locked up and both doors were to be closed. The [NAME] material safety data sheet (MSDS) for Vindicator+ revised 2/4/21, indicated the disinfectant/cleaner was hazardous to a person's health. The MSDS indicated to health hazards with exposure to eye, skin, or ingestion. The MSDS further indicated to seek immediate medical attention if ingestion or eye or skin contact occurred. The [NAME] MSDS for QT-TB revised 8/12/21, indicated the disinfectant/cleaner was hazardous to a person's health. The MSDS indicated to health hazards with exposure to eye, skin, or ingestion. The MSDS further indicated to seek immediate medical attention if ingestion or eye or skin contact occurred. The [NAME] Chemical Company MSDS for Barrier II revised 4/9/20, indicated the disinfectant/cleaner was hazardous to a person's health. The MSDS indicated to health hazards with exposure to eye, skin, or ingestion. The MSDS further indicated to seek immediate medical attention if ingestion or eye or skin contact occurred. The Genlabs MSDS for Pine Odor Control revised 11/4/20, indicated the disinfectant/cleaner was hazardous to a person's health. The MSDS indicated to health hazards with exposure to eye, skin, or ingestion. The MSDS further indicated to seek immediate medical attention if ingestion or eye or skin contact occurred. Facility policy titled Hazard Communication and Employee Right-to-Know dated 9/23, was to educate the employees of the hazardous substances, physical and infectious agents that may endanger their health and well-being while at work. Chemicals, through the different steps from their production to their handling, transport and use, may be a real danger for human health and the environment. People of any ages, from children to elderly, using many different languages and alphabets, belonging to various social conditions, including illiterates, were daily confronted to dangerous products (chemicals, pesticides, etc.)

Based on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 1 residents (R9) reviewed for call light accessibility. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively impaired and had diagnoses which included dementia, asthma, and hypertension (elevated blood pressure). Identified R9 was dependent on staff for activities of daily living (ADLs) which included bed mobility, toileting, and transfers. R9's care plan dated 1/28/25, identified R9 was at high risk for falls related to weakness, and age related osteoporosis, with an intervention dated 1/28/25, to be sure call light is within reach and encourage resident to use it for assistance as needed. During an observation on 3/23/25 at 2:00 p.m., R9 was seated in a stationary chair in her room about five ft. from her bed. R9's call light was attached to the bedrail out of R9's reach. During an observation on 3/23/25 at 2:01 p.m., on the bathroom door in R9's room was a sign that stated push call button for help. During an observation on 3/24/25 AT 8:35 A.M. R9 was seated in a stationary chair in her room about five ft. from her bed. R9's call light was attached to the bedrail out of R9's reach. During a joint interview on 3/24/25 at 8:40 a.m., nursing assistant (NA)-A and licensed practical nurse (LPN)-A verified R9's call light was attached to the bed rail and was not within reach of R9. NA-A and LPN-A verified R9 was able to use the call light. LPN-A stated her expectation was that R9's call light would be within reach. During an interview on 3/24/25 at 4:01 p.m., director of nursing (DON) verified R9 was able to use the call light. DON stated her expectations were that resident's call lights were within reach at all times so residents could call for assistance when needed. Review of a facility policy titled Call Lights: Accessibility and Timely Response revised 10/1/24, identified with each interaction in the resident's room or bathroom, staff would ensure the call light was within reach of the resident and secured, as needed.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R2) reviewed for medication errors was free of significant medication errors when orders for Warfarin (Coumadin) (a blood thinner used to reduce the risk of blood clots), was not transcribed into the electronic medical record according to physician's orders and resulted in six missed doses of Warfarin 5 milligrams (mg). Findings include: R2's telehealth visit with cardiologist on 11/20/24, identified stop Amiodarone (used to treat and prevent a number of types of irregular heartbeats) and Eliquis (used to prevent stroke and blood clots in patients with certain heart rhythm problem such as atrial fibrillation (A-fib) (an irregular and often very rapid heart rhythm and can lead to blood clots in the heart, increases the risk of stroke, heart failure, and other heart related complications), start taking Warfarin (Coumadin) 5 mg oral tablet daily according to the international normalized ratio (INR) (used to measure how long it took for blood to clot). R2's progress noted 11/20/24 at 6:58 p.m. R2 was seen by cardiology via telehealth today. Orders: stop Amiodarone and switch Eliquis to Coumadin 5 mg oral tablet daily, and then according to INR levels. Will clarify which clinic the results will go to and when INR checks to start. The communication documents with the Coagulation Clinic, INR nurse from 11/25/24 through 11/29/24 identified the following orders: -11/25/24, R2's finger stick INR result was 1.2 seconds with a therapeutic INR level while on warfarin 2 to 3 seconds. Current order began on 11/21/24, Coumadin 5 mg daily. Next INR scheduled for 11/29/24. Physician order: continue 5 mg by mouth (po) daily. Note: aware had only taken four doses to date. -11/29/24, R2's finger stick INR result was 2.4 seconds. Current order: Coumadin 5 mg daily. Next INR was scheduled for 12/5/24. Physician order: continue Coumadin 5 mg po daily. R2's primary provider medical doctor (MD) visit on 12/5/24, identified diagnoses: history congestive heart failure (CHF), diabetes mellitus (DM) insulin dependent with chronic kidney disease, atherosclerotic heart disease (buildup of fats, cholesterol and other substances in the artery of the walls called plague and can cause the arteries to narrow, blocking blood flow to organs and tissues), morbid obesity, chronic anticoagulation, deep vein thrombosis (blood clot) in lower extremities, A-fib, inferior vena cava (IVC) (big vein in the abdomen) filter (inserted into the IVC to catch/trap a traveling clot and prevent it from reaching the lung). She was started on Warfarin and a referral was placed to the INR clinic. INR was therapeutic with last check 2.4 on 11/9/24 [sic]. The communication documents with the Coagulation Clinic, INR nurse from 12/5/24 through 12/9/24 identified the following orders: -12/5/24, R2's finger stick INR result was 4.8 seconds. Current order: Coumadin 5 mg daily. Next INR was scheduled for 12/9/24. Physician order: hold today; 2.5 mg on 12/6/24 and 5.0 mg on 12/7/24 and 12/8/24. -12/9/24, R2's finger stick INR result was 2.9 seconds. Current order: Coumadin 5 mg daily. Next INR was scheduled for 12/16/24. Physician order: 2.5 mg on Mondays, Wednesdays, and Friday and 5 mg all other days. R2's December 2023 EMAR indicated: Warfarin 2.5. mg po in the evening on Monday, Wednesday, and Friday related to atrial fibrillation. Start date 12/9/24 at 6:00 p.m. and discontinue date 12/24/24 at 7:56 a.m., was administered on 12/9/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, 12/20/24, and 12/23/24. R2's December 2023 EMAR indicated: Warfarin 5 mg po in the evening on Tuesday, Thursday, Saturday, and Sunday for treating/preventing blood clots for two administrations. Start date 12/10/24 at 6:00 p.m. and discontinue date 12/24/24 at 5:46 p.m. Staff administered 5 mg on 12/10/24 and 12/12/24. On 12/10/24 the order for Warfarin 5 mg was transcribed inappropriately and entered on the EMAR as two administrations only. R2 did not receive Warfarin 5 mg dose as ordered on 12/14/24, 12/15/24, 12/17/24, 12/19/24, 12/21/24, and 12/22/24 (6 doses). The communication documents with the Coagulation Clinic, INR nurse from 12/16/24 through 1/14/25 identified the following orders: -12/16/24, R2's finger stick INR result was 2.3 seconds. Current order: Coumadin 5 mg Tuesday, Thursday, Saturday, Sunday, and 2.5 mg other days. Next INR scheduled: left blank. Physician order: Coumadin 5 mg po Tuesday, Wednesday, Thursday, and Saturday and Sunday; 2.5 mg Monday, Wednesday, and Friday. -12/24/24, R2's finger stick INR result was 1.2 seconds. Current order: 2.5 mg Monday, Wednesday, Friday, and 5 mg all other days. Next INR 12/31/24. Coumadin order: 5 mg tonight and 2.5 mg all other days. Handwritten on bottom of this document by INR clinic nurse was: 12/24/24 at 10:12 a.m. telephone call to staff nurse and upon looking at patient's medication list and EMAR, R2 had not received Coumadin 5 mg since 12/12/24, only the 2.5 mg dose Monday, Wednesday, Friday since then. Dosing of coumadin based on cumulative doses received. -R2's anticoagulant flow sheet dated 12/24/24 identified dosing plan for the week fax received from facility with INR 1.2 today. Telephone call (TC) to facility and checked on any changes or missed doses. Reported she had been getting 2.5 mg on Monday, Wednesday, and Friday but looks like she had not received Coumadin 5 mg tabs since 12/12/24. R2's order was placed wrong in computer, instead of ordered cumulative weekly dose of 27.5 mg she received 22.5 mg the week of 12/8/24 and only 7.5 mg the week of 12/15/24. Will have R2 take 5 mg tonight and then 2.5 mg daily and recheck INR in one week. Orders faxed to facility and pharmacy. -12/31/24, Diagnosis: A-fib. INR result today 1.4 seconds (goal 2 to 3). Dose increase by 12.5 %. Change coumadin dose: 5 mg po Thursday and Saturday and 2.5 mg Sunday, Monday, Wednesday, Thursday, and Friday. Recheck INR 1/7/25 (one week). -1/2/2025 10:05 a.m. R2's progress notes identified, Pharmacist Note: Medications and chart reviewed for monthly medication regimen review (MR) (a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication). No medication irregularities noted at this time. -1/7/25, R2's INR result today 1.6. Change coumadin dose to 5 mg Tuesday, Thursday, Saturday then 2.5 mg on Sunday, Monday, Wednesday, and Friday. Recheck INR on 1/14/25. -1/14/25, R2's INR result today 1.6. Increase dose by 10%. Change coumadin 5 mg po Sunday, Tuesday, Thursday, and Saturday; 2.5 mg Monday, Wednesday, and Friday. Recheck INR on 1/21/25. During an interview on 1/15/25 at 1:55 p.m. R2 stated she had a history of blood clots found in her legs, traveled to her lungs, and a filter was placed in her inferior vena cava. R2's last visit with her cardiologist was December 2024 and she had requested to be taken off Eliquis due to cost and placed on coumadin. She was started on Coumadin 5 mg with a therapeutic goal of INR between two and three and thought she had not received the correct doses of Coumadin. She stated the INR had been checked on Tuesdays and the result of the last one was below 2.0. She was concerned no adjustment had been made on the Coumadin dose and was afraid she was at an increased risk for another blood clot. During an interview on 1/16/25 at 11:30 a.m. medical doctor/medical director (MD) stated the INR clinic nurse helped manage R2's dosing of coumadin and she had written a note on 12/24/24 order form: R2 had not received her Coumadin for days due to the wrong order was placed in the computer. He would have expected staff to notify him right away, was out of the office on 12/24/24, and unsure when they discovered the transcription error. MD stated R2's missed doses of Coumadin contributed to a drop in her INR from 2.9 to 1.2, would have been considered subtherapeutic, and placed R2 at an increased risk for blood clots. During an interview on 1/16/25 at 1:45 p.m. registered nurse (RN) stated on 12/9/24, R2 had and INR of 2.9 and she had transcribed and signed off R2's orders for Coumadin 2.5 mg Monday, Wednesday, and Friday and 5 mg Tuesday, Thursday, Saturday, and Sunday. On 12/24/24 R2's INR had dropped to 1.2. She reviewed R2's December EMAR and noticed a transcription error, unsure why it had taken until 12/24/24 to realize this medication error. R2 was placed on Coumadin for her a-fib and when the INR dropped below 2 it increased R2's risk for blood clots. She stated the handwritten message and signature at the bottom of the 12/24/24 order document was the INR clinic nurse and identified the missed doses of Coumadin. During an interview on 1/16/25 at 3:37 p.m. pharmacist consult (PC) stated R2 had been taken off Eliquis, placed on Coumadin, and he was unaware of R2's missed doses of Coumadin. He stated once a resident was started on Coumadin it would have taken three to four days to achieve a therapeutic level versus Eliquis would have taken two days. R2's therapeutic level while on Coumadin was between two and three and if not within that window would have increased her risk of blood clots, stroke, and heart attack. During an interview on 1/16/25 at 4:30 p.m. director of nursing (DON) stated R2's Eliquis was discontinued and changed to Coumadin per her request due to cost. She stated on 12/24/24 R2's INR had dropped down to 1.2. R2 had missed six doses of Coumadin 5 mg due to a transcription error, probably lowered the INR level, and placed R2 at a risk for blood clots. The medication error was discovered on 12/24/24, and a new order was given that same day. Facility policy Medication Error dated 5/15/24, identified protection would be provided to all residents in the facility for the health, welfare, and rights by ensuring residents received care and services safely in an environment free of significant mediation errors. A mediation error was defined as the administration of medication which was not in accordance with the prescriber's order. Significant medication error was defined as one which jeopardized their health and safety. Medication errors, once identified, will be evaluated to determine if it would be considered significant by using the following guidelines: residents condition required rigid control such as monitoring of labs. Drug Category: if the medication is from a category that usually requires the resident to be titrated to a specific blood level such as medication with a narrow therapeutic index (NTI) such as Warfarin, and if the error occurred repeatedly such as omission of the resident's medication several times. If a medication error occurred the nurse would be expected to assess, examine the resident condition, and notify the physician or health care practitioner as soon as possible, monitor and document actions taken in the medial record, once stable report incident to supervisor, complete the incident or occurrence report.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 4 July 1st -September 30th, 2023), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 33 residents residing in the facility. Finding include: Reviews of the Payroll-Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 7/8/23, 7/9/23, 7/15/23, 7/16/23, 7/29/23, 7/30/34, 8/5/23, 8/6/23, 8/9/23, 8/20/23, 8/27/23, 9/9/23, 9/10/23, 9/21/23, 9/24/23, and 9/30/23 for failure to have licensed nurse coverage 24 hours per day. A review of the staffing schedules revealed the facility had licensed nurse coverage 24 hours per day. A review of the staff timecards identified the facility had licensed nurse coverage 24 hours per day. A review of the facility's staffing schedules and timecards identified discrepancies with the licensed nurse hours and the PBJ report. During an interview on 1/23/24 at 2:26 p.m., with nursing assistant (NA)-B stated there had always been a nurse on duty when she was scheduled. During an interview on 1/23/24 at 2:26 p.m., executive assistant (EA) stated the facility had licensed nurse coverage 24 hours per day on the days that were triggered on the PBJ. During an interview on 1/23/24 at 3:46 p.m., the administrator verified the facility had a licensed nurse 24 hours a day. The administrator verified timecards and staff schedules were accurate. Administrator confirmed there was a discrepancy between the PBJ, the licensed staff schedules and payroll forms. Administrator stated she believed the facility had submitted accurate data to CMS and felt the PBJ report was inaccurate. A policy titled Payroll Based Journal dated 12/4/22 was provided. The policy stated the facility was to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and editable data in a uniform format according to specifications established by CMS.

Based on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 11 of 11 residents (R21, R20, R9, R11, R25, R26, R18, R14, R29, R134, R135) who currently resided in those rooms. Findings include: During the entrance conference on 1/22/24, the administrator confirmed the rooms in the hallway A did not have at least 100 square feet of useable floor space as required. During the initial screening for residents on the A-wing on 1/22/23 at 11:39 a.m., the following resident rooms for R21, R20, R9, R11, R25, R26, R18, R14, R29, R134, R135 were observed to not have at least 100 square feet of useable floor space as required. On 1/22/23 at 11:38 a.m., R21 was observed to be resting in bed, unable to respond to questions regarding room size. A message was left for the guardian. On 1/22/23 at 5:45 p.m., the guardian returned the phone call and left a message and identified no concerns regarding the room size. -at 11:39 a.m., R20 stated she was happy with her room. R20's son reported no concerns with her room. -at 1:04 p.m., R9 stated her room was small. R9 chose her room when there were bigger rooms available. R9 had not requested to move to another room. -at 2:08 p.m., R25 stated her room was small, however she would not be staying long as she was returning home after she finished physical therapy. -at 2:17 p.m., R11 stated the room was big enough for her. -at 2:13 p.m., R26 stated the room was big enough as she did not do anything that required a lot of room. -at 2:56 p.m., R18 rested in bed, unable to respond to a question regarding room size. -at 4:54 p.m., R14 rested in bed, unable to respond to questions regarding room size. -at 1:45 p.m., R29 stated he had no complaints regarding room size and reported it was big enough for him. -at 1:58 p.m., R134 stated the room was big enough for him. -at 5:23 p.m., R 135 stated he would stay in the room. R 135 had no concerns with his room. The following rooms on the A-wing were unoccupied A-29 and A-30. During an interview on 1/24/24 at 1:23 p.m., nursing assistant (NA)-B stated no residents had complained about the size of their rooms. During an interview on 1/24/24 at 7:25 a.m., the director of nursing (DON) stated the facility would move a resident if they were not satisfied with their room. She had not heard of any complaints about room sizes. On 1/24/24 at 8:29 a.m., the administrator stated the rooms on the A-wing measured between 95.68 and 96.07 square feet. The administrator planned to apply for a waiver. Review of facility policy titled Change of room or Roommate dated 1/4/2, identified it was the policy of the facility to conduct changes to rooms when considered necessary and/or when requested by the resident or resident representative.

Based on observation, interview, and document review, the facility failed to ensure linen and personal laundry was transported and delivered in a manner that prevented the risk of contamination for one of three hallways observed for linen and laundry transportation. This deficient practice had the potential to affect 9 of the 33 residents residing at the facility. Findings include: Review of Centers for Disease Control (CDC) guidance, Appendix D- Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevents the risk of contamination by dust, debris, soiled linens, or soiled items. During an observation on 1/23/24 at 1:43 p.m., nursing assistant (NA)-A pushed the linen cart down hallway C. The front of the cart was not covered during transport. NA-A removed a hand towel and washcloth from the uncovered cart, knocked on R1's door and placed the hand towel and washcloth in the room. NA-A exited the room and removed a hand towel and washcloth from the uncovered cart. NA-A knocked on R24's door, entered the room, placed a hand towel and washcloth in the room and exited the room. NA-A took a hand towel and washcloth from the uncovered cart, knocked on R4's room, entered the room, placed the hand towel and washcloth in the room and exited the room. NA-A transported the uncovered linen cart to the storage room. NA-A did not sanitize her hands and the linen cart remained uncovered during the entire observation. During an observation on 1/24/24 at 9:54 a.m., environmental services (ES)-A, transported a laundry cart down hallway C with the front of the cart uncovered. ES-A removed clothes from the laundry cart that were on hangers, knocked on R22's door and entered. ES-A opened up R22's closet door, hung R22's clothes in the closet and closed the closet door. ES-A removed the empty clothes hangers from the closet and placed them in an uncovered laundry cart in the hallway to the right of the clean clothes. At 9:55 a.m., ES-A removed clean clothes from the uncovered laundry cart, knocked on R19's door, entered R19's room, opened the closet door, hung up R19's clothes and closed the closet doors. ES-A removed clean clothes from the uncovered laundry cart, knocked on R3's door, hung up clothes in the closet, closed the closet doors and returned to the uncovered laundry cart. ES-A removed clean clothes from the uncovered cart, knocked on R28's door, hung clothes in the closet, removed empty hangers from the closet and hung in the uncovered laundry cart. At 9:56 a.m. ES-A removed clean clothes from the laundry cart, entered R6's room and hung up clothes in the closet. ES-A removed hangers from the closet, closed the closet door and hung up the hangers in the uncovered cart. At 9:57 a.m., ES-A removed clothes from the uncovered cart and knocked on R28's door. ES-A entered the room, placed the clothes in the closet and closed the closet door. ES-A exited R28's room, removed clothes from the uncovered laundry cart and knocked on R10's door. ES-A hung clothes up in the closet, removed empty hangers, closed the closet door and exited the room. ES-A hung the hangers in the uncovered laundry cart. At 9:58 a.m., ES-A removed clothes from the uncovered laundry cart, knocked on R24's door, introduced herself while entering the room, hung the clothes up in the closet and removed the empty hangers. ES-A closed the closet door, exited the room and placed the hangers in the uncovered laundry cart. At 9:59 a.m., ES-A removed clothes from the uncovered laundry cart and knocked on R1's door. ES-A entered R1's room, hung up clothes in the closet, removed empty hangers and closed the closet door. ES-A exited the room and placed the hangers in the uncovered laundry cart. ES-A removed clothes from the uncovered laundry cart, knocked on R4's door, introduced herself while entering the room and hung the clothes in the closet. At 10:00 a.m., ES-A closed the closet door, exited the room and transported the uncovered laundry cart to the laundry room. ES-A did not sanitize her hands and the laundry cart remained uncovered during the entire observation. During an interview on 1/23/24 at 1:48 p.m., NA-A reported her normal process was to cover the linen cart when transporting and passing linen. NA-A verified she did not cover the laundry cart when passing linens in hallway C. NA-A confirmed she did not sanitize hands during the above listed observation. During an interview on 1/24/24 at 10:14 a.m., ES-A stated the process when delivering the laundry was to cover the laundry cart. ES-A verified she did not sanitize her hands when she was delivering laundry as she was only handling clean clothes. In addition, ES-A verified the laundry cart had been left uncovered during the delivery. ES-A indicated it was important to sanitize her hands to prevent cross contamination from room to room. During an interview on 1/24/24 at 10:31 a.m., the director of nursing (DON), who also works as the infection preventionist, reported it was her expectation that when transporting linen and laundry, the staff were to keep clean and dirty items separate, sanitize hands, and keep the linen and laundry carts covered. During an interview on 1/24/24 at 10:42 a.m. administrator stated her expectation was for staff to treat everything as dirty and wash hands between rooms to prevent cross contamination. Review of facility policy titled handling linen dated 2017, indicated laundry was delivered in a covered clean linen cart to prevent contamination while being moved though the facility. Review of facility policy titled hand hygiene dated 6/23/23 indicated staff would perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. The policy applied to all staff working in all locations within the facility.

Based on interview and document review, the facility failed to ensure written notification of the reason for transfers were provided to the residents or resident representatives for 2 of 3 residents (R24, R19) reviewed for hospitalization . Findings Include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 was cognitively intact with diagnoses which included: heart failure, end stage renal disease, and diabetes mellitus. R24's MDS identified R24 required set up or assistance with eating, oral hygiene and upper body dressing. Review of R24's progress notes from 9/15/23 to 10/15/23, identified the following: -10/2/23 at 6:13 a.m., R24 was clammy, diaphoretic (perspiring), and nauseated. R24's speech was incoherent and R24 was unable to communicate his needs with general weakness. Emergency medical services (EMS) was called at 6:00 a.m., bed hold obtained, and all responsible parties notified. R24 left facility at 6:10 a.m. to hospital. -10/3/23 at 12:28 p.m., spoke with dialysis nurse, R24 admitted to hospital with pneumonia (PNA) and received antibiotics. -10/4/23 at 9:45 a.m., R24 unexpectedly hospitalized [DATE]. R24 returned to the facility on [DATE]. Review of R24's electronic health record (EHR) revealed no documentation the resident or resident's representative had received a written notification of R24's transfer. During an interview on 1/24/24 at 8:34 a.m., assistant director of nursing (ADON) reviewed R24's EHR and confirmed R24 went to the hospital on 10/2/23, and the facility was notified of R24's hospital admission on 10/3/23. ADON confirmed R24's EHR lacked documentation a written notification of the transfer had been provided to the resident or the resident representative. ADON indicated the facility's usual process was to mail out a copy of the reason for transfer, with the the facility's bed hold policy at time of transfer to the resident's representative or provide to the resident. During an interview on 1/24/23 at 9:57 a.m., director of nursing (DON) verified R24 had been transferred to the hospital on 10/2/23, and R24's EHR lacked documentation a written notification of transfer had been provided. DON stated it was important to provide the written notification of transfer so family or representatives were aware of what happened and if there were questions they could contact the facility. DON indicated the facility did not have a process to assure documentation of written notification of transfers was completed. 49620 R19 R19's MDS dated [DATE], indicated R19 had severe cognitive impairment and had diagnosis which included severe intellectual disability, Chronic Ulcerative Rectosigmoiditis (disease that causes inflammation and ulcers in the digestive tract), Anxiety, Cerebral Palsy (condition that affects movement and posture), constipation. Identified R19 required extensive staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Review of R19's progress notes on 3/25/23, revealed the following: - At 1:19 p.m., R19's abdomen was distended, noted to be hard upon percussion. R19 had shook his head up and down indicating yes when staff asked if he wanted to go to the doctor. Call was placed to R19's guardian, she did not answer, message left. R19 was sent to emergency room . - At 7:37 p.m., progress note stated in hospital. - At 9:44 p.m., progress note reported R19 was admitted with a bowel obstruction. Message was left for R19's guardian. R19's medical record lacked documentation R19's representative had received a written notification of the reason for transfer. Review of R19's progress notes on 4/15/23, revealed the following: - At 12:34 p.m., R19 had absent bowel sounds. Call was placed to guardian regarding bed hold. All responsible parties were notified of transfer. - At 4:28 p.m., progress note indicated R19 was admitted to the hospital. R19's medical record lacked documentation R19's representative had received a written notification of the reason for transfer. During an interview on 1/24/24 at 8:43 a.m., ADON confirmed R19 had been hospitalized both dates and stated that there was no written transfer notification in R19's medical record for either hospitalization s. ADON verbalized a written transfer notice was important to ensure appropriate parties had been notified and were aware of the reason for transfer. During an interview on 1/24/24 at 10:09 a.m., DON confirmed the above findings and indicated a written transfer notification was important to ensure responsible parties were aware of hospitalization and the expectation of nursing was to complete a transfer form and send to the receiving facility. Review of a facility policy titled, Transfer and Discharge (including AMA) revised 6/1/23, lacked documentation of a process for notifying the resident and or the resident representative of the transfer in writing for emergency hospital transfers.

Based on interview and document review, the facility failed to provide notification to the resident and/or resident's representative of the facility's bed hold policy at the time of emergency transfer and hospitalization s for 1 of 4 resident (R19) reviewed for hospitalization . Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 had severe cognitive impairment and had diagnosis which included severe intellectual disability, Chronic Ulcerative Rectosigmoiditis (disease that causes inflammation and ulcers in the digestive tract), Anxiety, Cerebral Palsy (condition that affects movement and posture), constipation. Identified R19 required extensive staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Review of R19's progress notes on 3/25/23, revealed the following: - At 1:19 p.m., R19's abdomen was distended, noted to be hard upon percussion. R19 had shook his head up and down indicating yes when staff asked if he wanted to go to the doctor. Call was placed to R19's guardian, she did not answer, message left. R19 was sent to emergency room . - At 7:37 p.m., progress note stated in hospital. - At 9:44 p.m., progress note reported R19 was admitted with a bowel obstruction. Message was left for R19's guardian. R19's medical record lacked documentation that R19's representative had been notified of the facility's bed hold policy. Review of R19's progress notes on 4/15/23, revealed the following: - At 12:34 p.m., R19 had absent bowel sounds. Call was placed to guardian regarding bed hold. All responsible parties were notified of transfer. - At 4:28 p.m., progress note indicated R19 was admitted to the hospital. R19's medical record lacked documentation that R19's representative had been notified of the facility's bed hold policy. During an interview on 1/24/24 at 8:43 a.m., assistant director of nursing (ADON) confirmed R19 had been hospitalized both dates and stated that there was no written notice of bed-hold in R19's medical record for either hospitalization . ADON verbalized a bed-hold notice was important to ensure appropriate parties were notified and would allow the resident to return to the facility. During an interview on 1/24/24 at 10:09 a.m., director of nursing (DON) confirmed the above findings and indicated a bed-hold notification was important to ensure responsible parties were allowed the option to hold their bed. DON verified the expectation of nursing was to complete a bed-hold notice with all transfers. The facility bed-hold policy was requested however the policy was not provided.

Based on interview, document review, and observation, the facility failed to ensure a door alarm was activated at all times, which resulted in 1 of 3 residents (R1) leaving a secured area, out onto concrete steps in his wheelchair, which placed R1 at risk for serious injury, harm or death. The Immediate Jeopardy (IJ) began on 9/14/23, at 8:00 a.m. when staff had disarmed the WanderGuard system, and R1 went out the door and was found on the cement steps with his wheelchair leaning on top of his head at 11:15 a.m. The IJ was identified on 9/21/23, at 3:30 p.m. and the administrator and nurse consultant were notified of the IJ. The facility had immediately implemented corrective action on 9/14/23, therefore the IJ is being issued at past noncompliance. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, was sometimes able to understand and be understood by others, with diagnoses including traumatic brain dysfunction related to traumatic brain injury (Injury to brain function). R1's care plan with revision date of 8/7/23 indicated use of a WanderGuard (alarm system attached to door which sounds an alarm when a resident with a WanderGuard bracelet on approaches a door that is opened) due to history of wandering with additional interventions to engage resident, clearly identify R1 room and bathroom, and schedule time for regular walks. R1's elopement assessment dated [DATE] identified resident at risk for elopement with history of wandering, wandering aimlessly, and resident not accepting of admission. R1's facility nursing home incident report (NHIR) Vulnerable Adult report dated 9/14/23 indicated R1 had left the facility and exited the building unwitnessed, where he had been found outside at 11:15 a.m. due to a WanderGuard system failing to alarm because a physical therapy assistant (PTA)-B had turned off the WanderGuard system. R1's facility 5-day Vulnerable Adult Report dated 9/18/23 indicated that WanderGuard system had been disabled by therapy staff, PTA-B and R1 was noted sitting on steps outside the administrative wing with his wheelchair leaning on his back. During observation on 9/20/23 at 10:15 a.m., front desk receptionist (FDR) was seen redirecting resident away from entrance door and explained to surveyor R1's WanderGuard had prevented him from opening the door. PTA stated there was another WanderGuard system on the other end of the facility. During observation on 9/20/23 at 12:37 p.m., R1 was in the dining room space with WanderGuard noted on resident wrist. When interviewed on 9/20/23 at 12:50 p.m., FDR stated he was very familiar with R1 and that R1 was constantly moving around and trying to get out. FDR stated on the day of R1 being found outside, the other WanderGuard system had been turned off and R1 had been first met on the steps by Physical Therapy Director (PTD)-C. FDR stated that education on proper use of the WanderGuard system had been provided to him on 9/14/23. When interview on 9/20/23 at 1:06 p.m., PTA-B stated he was familiar with R1, had worked with him in the past, and was aware that on many occasions he had tried to leave the facility. PTA-B stated R1 had once tried to get over a fence and was strong for his age. PTA-B stated he had turned off the WanderGuard at some point in the morning of 9/14/23, maybe around 8:00 a.m., but I had the doors still shut. PTA-B stated when he arrived to R1 outside on the cement steps that R1's wheelchair was at the top of the steps. PTA-B stated R1 could have been hurt from the incident and that he won't be turning off the WanderGuard system again and is no longer allowed to. PTA -B stated education on proper use of the WanderGuard system had been provided to him on 9/14/23. When interviewed on 9/20/23 at 1:24 p.m., PTD-C stated she was familiar with R1 and that he was a bit of an escape artist and moved quickly at times. PTD-C stated on 9/14/23 about 11:15 a.m., a passerby from the community had come through the administrative wing doors and notified the facility R1 was outside on the steps with a wheelchair over his head. PTD-C went outside immediately. R1 was sitting on the third or fourth step cement step outside with the back of the wheelchair leaning on his head. PTD-C stated R1 was trying to scoot down the steps as they tried to assess him. PTD-C showed surveyor steps R1 was found outside and they had 7 or more cement steps. PTD-C stated she had been reeducated on proper use of the WanderGuard on 9/14/23. During observation on 9/20/23 at 1:37 p.m., surveyor reviewed site where R1 was found outside by PTD-C. The exit door went to cement platform estimated 5 feet wide by 6 feet long with ramp on side and 7 cement steps led down to a short cement sidewalk of estimated 5 feet wide by 6 feet long in size with a cement street curb that led to a tarred street road for motor vehicles. No alarms noted on exit door leading out to cement steps. When interviewed on 9/20/23 at 3:05 p.m., PTA-B showed surveyor where he had turned off the WanderGuard alarm to the doors at the end of B wing before going towards administrative hall and exit door where R1 was found. PTA-B demonstrated to surveyor how he had turned off WanderGuard with a key within a lock box, and stated the yellow light indicates it on and the green light indicates the alarm is off. PTA ensure the system was armed and said he had not seen anyone else turn off WanderGuard alarm system on 9/14/23. When Interviewed on 9/20/23 at 3:16 p.m., licensed practical nurse (LPN)-A stated she had been working the medication cart on 9/14/23 at the time of R1 being found outside at 11:15 a.m., and that she had seen him 10 to 20 minutes earlier. LPN-A stated she did not recall hearing the WanderGuard alarm. Further, she would never turn off the WanderGuard alarm system. LPN-A stated education on proper use of the WanderGuard system had been provided to her on 9/14/23. When Interviewed on 9/20/23 at 3:45 p.m., environmental services director (ESD)-E stated he had been approached by the administrator immediately following the incident on 9/14/23 and began in person education at the site of the WanderGuard system with staff throughout the facility. ESD-E stated the education reviewed how to identify if the system was properly armed, how to properly arm if noted off, and that staff should not be turning off the system. ESD-E also produced a document showing who had participated in education from the facility, and that 2 staff who had not yet worked were still needing to be educated. They would be educated prior to working their next shift. During Observation on 9/21/23 at 9:01 a.m., PTD-C seen transferring R1 through doors at end of B wing hallway and WanderGuard alarm system sounding. PTD-C reset the alarm and yellow light indicator was on following reset. When Interviewed on 9/21/23 at 9:07 a.m., trained medical assistant (TMA)-A stated R1 is a known wanderer and only R2 and R3, who also tended to wander in the facility, have ever been seen coming down the B wing hall toward the therapy doors often. TMA-A stated other residents are using a WanderGuard, but it is often just R1, R2, and R3. TMA-A stated that she works the hallway often and is familiar with the residents. When interviewed on 9/21/23 at 9:42 a.m., facility rounding physician (FRP-D) stated he had assessed R1 following the incident on 9/14/23. FRP-D stated the resident seemed confused, and was, thankful okay, and it could have been a major event. When interviewed on 9/21/23 at 9:49 a.m., PTA-B stated he had learned how to turn off the WanderGuard system from a staff member in the past but could not recall exactly who and when. PTA-B stated he had turned it off that day because it can been bothersome to other residents with WanderGuard devices, who were already hesitant to go through the WanderGuard alarm system towards the therapy space, such as, R3, as it alarms loudly. When interviewed on 9/21/23 at 12:43 p.m., registered nurse (RN)-B stated she had assessed R1 on 9/14/23, after being found outside in the middle of the steps and transferred R1 back through the WanderGuard doors that had been turned off where R1 had exited. RN-B stated the doors had been turned back on by PTA-B around 11:30 a.m. and she verified that the WanderGuard system had been turned on at that time. The past non-compliance immediate jeopardy which began on 9/14/23. At 8:00 a.m. was removed, and the deficient practice corrected by 9/14/23, at 11:30 a.m., after the facility implemented a systemic plan that included the following actions: R1 removed from potential harmful space and assessed by facility trained nursing staff and physician with notification provided to resident guardian. Facility WanderGuard system rearmed and verified operational. Facility staff PTA-B reeducated on proper use of WanderGuard alarm system and not allowed to turn off WanderGuard system and can only be reset by PTD-C, or facility nursing staff. Facility wide education of WanderGuard system completed for all facility staff on 9/14/23. Facility investigation into cause of WanderGuard system being deactivated, and root cause of system deactivation performed. Facility document, titled, Elopements and Wandering Resident Policy indicated the facility is equipped with door locks/alarms to prevent elopements. Facility document, titled, Abuse, Neglect and Exploitation Policy indicated Minnewaska Lutheran Home is to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R16) reviewed for pressure ulcers. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, identified Section M: Skin Conditions to be completed with an intent to document the risk, presence, appearance, and change of pressure ulcers. Further, the manual provided several coding instructions, including completing question M0100A and M0210A and M0300A, directing staff to, Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer risk assessments. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident. R16's quarterly Minimum Data Set ( MDS) dated [DATE], Section M: Skin Conditions question M0100A identified R16 had no stage I or greater pressure ulcer. Further, M0210 identified R16 did not have one or more unhealed pressure ulcer(s) at stage one or higher. M0300B indicated, R16 did not have a current stage two pressure ulcer. R16's Care Area Assessment (CAA) for pressure ulcer dated 12/14/21, indicated R16 was at risk for pressure ulcers related to the need for extensive assistance with activities of daily living ( ADL's.) R16's CAA identified routine skin checks had been completed. R16's Care plan updated 8/17/22, indicated R16 had a pressure ulcer. R16's interventions included a mattress overlay, a pressure relieving cushion in wheelchair and frequent repositioning. R16's Braden assessment dated [DATE], identified R16 was at moderate risk for pressure ulcers with a score of 13. A progress noted dated 8/17/22, indicated R16 had a stage two pressure ulcer to her right gluteal fold and an allevyn gentle border dressing was placed for advanced healing. A progress noted dated 8/30/22, indicated R16's wound was stable and stated to continue same treatment. A progress noted dated 9/12/22, indicated R16 had no skin concerns. Review of R16's wound assessment dated [DATE], identified R16 had a 1.2 x 0.6 stage two pressure ulcer on her right gluteal fold. Wound assessments dated 8/24/22, 9/7/22, 9/14/22, 9/24/22, identified a stage two pressure ulcer was still present on R16's right gluteal fold. Wound assessments dated 10/2/22, 10/6/22,10/13/22,10/20/22, indicated the pressure ulcer to R16's right gluteal fold had become unstageable. Review of the observation detail list report dated 9/12/22, indicated R16 was at risk for pressure ulcers however lacked evidence of a pressure ulcer. During an interview on 10/27/22, at 10:00 a.m. registered nurse (RN-A) verified R16 had a stage two pressure ulcer on her right gluteal fold at the time R16's MDS was completed. RN -A verified R16's MDS dated [DATE], had been coded incorrectly. During an interview on 10/27/22, at 10:30 a.m. assistant director of nursing (ADON) verified R16 had a stage two pressure ulcer on her right gluteal fold at the time R16's MDS was completed. ADON confirmed R16's MDS dated [DATE], had been coded incorrectly for pressure ulcers. ADON stated her expectation was the MDS would have been coded correctly. Review of a facility policy titled MDS 3.0 Completion indicated the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state. Policy further indicated all disciplines should follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment

Based on observation, interview and document review, the facility failed to provide assistance with routine grooming which included facial hair removal for 1 of 3 residents (R13) who required assistance with grooming and personal hygiene. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R13 had severe cognitive impairment and required assistance with activities of daily living (ADL's) of dressing, personal hygiene, and bathing. The MDS identified R13 had no refusal of cares during the seven day look back period. R13's current care plan revised 9/24/22, revealed R13 required assistance with ADL's due to [CONDITION(S)], dementia, and weakness. The care plan revealed R13's facial hair would be removed daily and as needed. On 10/24/22, at 2:39 p.m. R13 was observed seated in a wheelchair in the dining room, following a facility activity. R13 was observed to have several dozen, white, thick, course chin hairs approximately four (4) to five (5) millimeters (mm) in length and had several white wispy chin hairs approximately 10-15 mm long. R13 had a plate in front of her with a half eaten piece of birthday cake. On 10/25/22, at 9:15 a.m. R13 was observed seated in a wheelchair in the dining room at a table by the window. R13 was eating hot cereal and continued to have several dozen thick, course, approximately 4-5 mm long hairs along her chin along with several long, white, wispy chin hairs approximately 10 mm long. During a telephone interview on 10/24/22, at 6:50 p.m. with R13's family member, (FM)-A indicated she had recently visited R13 the previous Friday and had noticed she had a lot of facial hair along her chin and lip line. FM-A indicated R13's appearance had been very important to her and would have wanted her facial hair removed routinely. FM-A indicated she had spoken to a facility staff member in the past, approximately a month ago, requesting R13's facial hair be shaved off as needed. She indicated she felt R13 would have been upset if she knew she had been in a public area without being shaved. On 10/26/22, at 8:36 a.m. R13 was observed lying in bed on her back, her eyes were open, she was smiling. R13 continued to have several dozen thick, course, approximately 4-5 mm long hairs along her chin along with several long, white, wispy chin hairs approximately 10 mm long. At that time, nursing assistant (NA)-A entered R13's room and proceeded to assist her with morning cares and up into her wheelchair and was wheeled to the dining room for breakfast. NA-A was not observed to remove R13's facial hair. -at 9:26 a.m. R13 remained seated in her wheelchair in the dining room, she ate her breakfast independently. R13 continued to have several dozen thick, course, approximately 4-5 mm long hairs along her chin along with several long, white, wispy chin hairs approximately 10 mm long. During an interview on 10/26/22, at 11:58 a.m. NA-A indicated R13 required assistance with her ADLs of dressing, grooming, personal hygiene, and bathing. NA-A indicated R13 had cognitive impairment and was not always able to verbalize her needs on a routine basis. NA-A confirmed R13 had facial hair on her chin, and she had not removed R13's facial hair with her morning cares. She indicated she had shaved R13 the day prior, and had missed a few areas. During an interview on 10/27/22, at 10:58 a.m. the assistant director of nursing (ADON) indicated R13's family was very involved in her care and routinely visited her in the facility. The ADON stated she expected R13 would be well groomed and would have her facial hair removed as needed. Review of an undated facility policy titled, Grooming a Resident's Facial Hair, revealed it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice.

Based on observation, interview and document review, the facility failed to complete a root cause analysis and develop interventions to prevent reoccurring falls for 1 of 3 residents (R1) which resulted in R1 falling 11 times causing one fracture, and minor injuries that required first aid. This resulted in an immediate jeopardy (IJ) situation for R1 who remained at risk for serious injury from frequent falls. The IJ began on 8/17/21, when R1 had 3 falls requiring emergency services in 48 hours which resulted in a wound over his eyebrow requiring Steri-Strips, a new bruise on right shoulder, right eye was still bruised and swollen and was admitted to the hospital and determined to have a right hand, 5th metacarpal fracture. The facility had no evidence of completing post fall root cause analysis or developing and implementing new interventions as a response to the falls. On 8/27/21, at 3:49 p.m. the director of nursing (DON) and administrator were notified of IJ for R1. The IJ was removed on 8/30/21, at 5:06 p.m., however non-compliance remained at an isolated scope and severity of a G, actual harm that is not immediate jeopardy. Findings include: R1's admission minimal data set (MDS) dated [DATE], indicated R1 had diagnoses which included hip fracture, anxiety disorder and had severely impaired cognition. Further review of MDS, indicated R1 required extensive assistance of one staff member for most activities of daily living which included bed mobility, ambulation in room, dressing, and toileting. R1's care plan dated 8/27/21, indicated R1 was at risk for falls related to diagnosis of history of falls and right hip fracture. Interventions for R1's falls included stop sign placed in room 8/24/21, fall mats at bedside 8/18/21, night light 8/13/21, frequent reminders for resident to use call light and ask for assistance before ambulation/transfers 8/3/21, re-orientate resident to call light use and safe transfers 8/2/21, call don't fall sign placed in resident's room 7/22/21, and 7/21/21, assist with mobility, medications as ordered, anticipate needs, call light within reach, adequate lighting allowed, room free from clutter. Review of R1's progress notes are as follows: On 7/22/21, R1 had unwitnessed fall at approximately 7:00 a.m. this morning. Immediate intervention of call don't fall sign put in R1's room. On 7/22/21, interdisciplinary team (IDT): R1's fall from 7/21/21, was discussed during meeting. R1 is on 15-minute checks and interventions will be to place call don't fall signs in R1's room. On 7/26/21, certified nursing assistant reported that she was ambulating R1 to bed from recliner and resident became weak and was eased to the floor. R1 did not sustain injury. Immediate intervention placed included staff will continue to do frequent checks on R1 and provide tender loving care (TLC). On 7/27/21, IDT meeting to discuss 7/26/21, fall concluded will continue with current fall preventions. Will also continue with PT [physical therapy]/OT [occupational therapy] as ordered to aid in transfers/ambulation. On 7/31/21, R1 had unwitnessed fall in room. R1 self-ambulated over to his closet using his walker and then fell into the closet breaking the door. Abrasion noted to right arm, cleansed and [MEDICATION(S)] applied. Immediate intervention implemented resident re-educated to call light. On 8/2/21, IDT met to discuss 7/31/21, fall interventions will remain, in addition to reorientation to use of call light, and transfer assistance with staff present. Approximate 15-minute checks will continue with documentation to be done via paper. On 8/2/21, R1 had unwitnessed fall in his room. R1 reported hitting his head, back of head swollen. R1 had complaints of headache. 911 called and resident sent to ER [emergency room ] for further evaluation for immediate intervention. R1 will be spending at least one night d/t [due to] a skull fracture. On 8/4/21, IDT met to discuss R1's fall on 8/2/21, Resident's room remains free of clutter, appropriate footwear worn and on during time of fall, and call don't fall signs were in place. Nursing order discharged for 15-minute checks due to intervention not being effective. Interventions will remain, in addition to reorientation of use of call light, and transfer assistance with staff present. On 8/6/21, R1 had unwitnessed fall in bedroom. R1 did not sustain an injury. Immediate intervention implemented included will continue to monitor resident. Re-educated resident on use of call light. No progress notes for the IDT meeting to discuss R1's fall on 8/6/21. On 8/16/21, R1 had witnessed fall while self-ambulating unattended in the hallway. R1 was witnessed to bump his head, but no injuries noted at this time. Progress note lacked evidence that an immediate intervention was implemented to prevent future falls. On 8/17/21, IDT met to discuss R1's 8/16/21, fall Intervention put into place is to continue to educate resident to ask for assistance. It was also discussed that resident will be transitioning to memory care unit when opening is available. Resident is out of isolation and will be able to participate in activities and come out to meals. On 8/17/21, R1 had unwitnessed fall in R1's room. R1 was face down alongside R1's bed. R1 was noted to have blood coming from right eyebrow line. Pressure immediately placed. Wound cleaned and Steri-Strips placed over eyebrow. 911 called and updated hospital on transfer. R1 left facility at 7:00 p.m. via ambulance. On 8/17/21, R1 returned to the facility at 10:40 p.m. On 8/18/21, R1 had unwitnessed fall at 5:15 a.m. in the morning. R1 was found sitting on the floor mat that was placed on the evening of 8/17/21, after fall. R1 was noted to have a new bruise on right shoulder, right eye was still bruised and swollen no other injuries were noted. Immediate intervention was call light given to resident and reminded him to use call light. Floor mat back in place and bed lowered. On 8/18/21, IDT met to discuss R1's two falls within the last 24 hours. he did sustain a small laceration near right eyebrow and has bruising to right hand, right shoulder, and right eye. Room was uncluttered, fall mats at bedside, proper footwear in place. IDT review and intervention is to continue with frequent reminders and re-education for call light use, On 8/19/21, R1 had unwitnessed fall at 10:00 p.m., in bathroom near the front of the facility. There was no injury observed. Ambulance arrived at 10:45 p.m. to pick up R1. On 8/20/21, R1 was admitted to the hospital for an infection of unknown origin and R1 had a boxer's fracture in his right hand. Resident's right hand, 5th metacarpal is fractured, and he is being fitted for a splint. On 8/20/21, IDT met related to fall, medication changes at hospital, [MEDICATION(S)] was decreased, with blood pressure parameters. No other recommendations at this point. No additional notes were included as to the cause or incident related to fracture. On 8/23/21, family declines the need for Memory Clinic at this time and would like no changes to occur with his [CONDITION(S)] medications at this time. Discussion of bladder training, and family declined this due to resident not being successful in the past. Will continue to revisit at a later date. On 8/23/21, R1 was observed in the grass at the building next door to the facility. R1 was transferred by ambulance for further evaluation. On 8/23/21, R1 had unwitnessed fall in his room. R1 was found on the floor mat laying on his right side. R1 sustained skin tear to both elbows. Progress note lacked evidence of an immediate intervention to prevent future fall and injuries. On 8/24/21, IDT met to discuss previous falls from 8/23/21. WanderGuard was placed on resident. Stop signs placed in resident room. Call light will be switched to a flat bottom. Family declines the need for a pendant call light, stating they felt resident would not understand how to use it. During observation on 8/27/21, at 7:43 a.m. R1 was lying in bed on his right side. R1's bed was lower to the floor and floor mat was next to bed. On R1's left side of the bed, there was a silver triangle call system. The call light was observed hanging from the left side of R1's bed and was upside down. This call light was placed as a fall intervention after R1's latest fall on 8/24/21, however this call light would not have notified staff as intended by the way it was hanging upside down off the bed rendering it in operable. In addition, there were two paper signs taped to R1's bathroom door one being a stop sign and the other said Call Don't Fall despite R1's cognition status being severely impaired. On 8/27/21, 7:46 a.m. licensed practical nurse (LPN)-A poked her head into R1's room and continues to walk down the hall. R1's call light continued in the same position. On 8/27/21, at 7:48 a.m. DON entered R1's room and stated, sound asleep. R1's call light continued in the same position. On 8/27/21, at 8:04 a.m. LPN-A again poked her head into R1's room and continued to walk down the hall. R1's call light continued the same. On 8/27/21, at 8:20 a.m. nursing assistant (NA)-A and NA-B enter R1's room to assist with morning cares. When asked about the call light hanging upside down off R1's bed, NA-A stated if he moves or stands up it is motion censored, so it alerts staff quickly and placed it back as before hanging off the bed upside down on the left side. On 8/27/21, at 3:21 p.m. LPN-B indicated the fall procedure included looking at the situation and see what we could have been done to prevent the fall. We [staff] place an immediate intervention usually in the notes and it is care planned for what we did. Further, LPN-B indicated R1 was a high fall risk and had poor cognition. When asked what interventions were in place for R1's falls, LPN-B responded, 15-minute checks, call don't fall sign, and floor mat. On 8/27/21, at 8:55 a.m. when asked what the facility's fall procedure was, NA-B stated we [staff] set a protocol to keep them [residents] from falling again. We think what will prevent another fall, so it doesn't happen again. Sometimes it's a little tricky. We try to keep them safe like a floor mat or monitoring them one on one if we have to sit there we do. We try to take every step we can keep them safe. Further, NA-B indicated R1 was a high fall risk and is beginning to have sun-downers [state of confusion that occurs later in the afternoon and into the night most often found in patients who have dementia or Alzheimer's disease.] in the evenings and that is when he has taken a tumble usually. NA-B stated R1 has had a lot of falls and indicated R1's fall interventions included the floor mat, monitor R1 every 10 minutes at least, sensor on his bed and low bed. In addition, when asked about the sensor on his bed NA-B stated, R1 is not able to use the call light appropriately and that is another reason why they moved to the bed sensor as it will detect any movement and senses his body moving or getting out of bed and will make a beeping noise to alert staff he is moving. However, NA-B continued to state, I don't think [R1] would know how to use his call light that is why [R1] was on the floor so many times. On 8/27/21, at 9:22 a.m. when interviewing family member (FM)-A on what the facility had put into place for fall interventions to prevent future falls and injury, FM-A stated This is so touchy. They [staff] said [R1] is on 15-minute checks, but there is no way they can do that, they lowered the bed to the floor and put a mat next to the floor to prevent injury and we have moved rooms. Further, I really have not got anything on how they are preventing falls honestly. I know from being there that the 15-minute checks are not being done when family is there and they don't know when I am there or when I leave. On 8/27/21, at 9:40 a.m. when asked about the facility fall procedure, LPN-A stated, we [staff] try to figure out what happened and try to put an intervention in place. For example, if they [residents] are falling in their room out of bed, we would put a pad down or call don't fall signs if appropriate. When asked when placing a call don't fall sign would not be an appropriate intervention for a resident post fall, LPN-A stated it wouldn't be appropriate if they can't see or if they are not cognitively intact. We will try it, but they usually don't help. Further, LPN-A identified R1 was a high fall risk and had dementia behaviors. In addition, when asked what interventions were in place to prevent R1 from falling, LPN-A stated, we keep an eye on him between everyone in the building, 15-minute checks, and he has a wander guard on, that is all I can think of. On 8/27/21, at 10:26 a.m. when asked about the facility fall procedure, registered nurse (RN)-A indicated we [staff] investigate and find out more. We put immediate interventions in and assess it [fall] the next day in IDT and come up with a better plan if there is one. RN-A indicated R1 showed some confusion related to his dementia and was a fall risk. Further, RN-A indicated after R1's fall on 7/26/21, there were no interventions placed in R1's care plan but the immediate interventions were frequent checks and TLC (tender loving care). RN-A then stated for 7/31/21, post fall interventions were remained free of clutter, sign posted, frequent checks, reorientation to call light and reorientation to staff transfer assistance with staff present. Further, RN-A indicated 8/2/21, post fall immediate intervention was sending R1 to the emergency room and when R1 returned from the hospital interventions placed were again reorientation to call light, staff assistance, free of clutter, sign in room, frequent checks already had all that in place but the immediate was the ER evaluation and when he came back, we were trying to re-educate him. However, RN-A stated, I think [R1] will sometimes remember to use the call light, but there was no new intervention added. RN-A continued to review R1's fall on 8/2/21, stated this fall he got the skull fracture, that is why he spent the night in the ER, when he came back, we did not place a new intervention to prevent falls. RN-A stated referring to fall on 8/6/21, immediate intervention was reeducation on the call light. IDT meeting there was nothing new added for an intervention. We made sure there was a night light on in his room, but that night light was placed on 8/13/21 so that was not immediate, it was after. Referring to R1's fall on 8/16/21, RN-A stated, there was no new intervention placed and IDT meeting stated to continue to re-educate. Referring to R1's fall on 8/17/21, RN-A indicated the immediate intervention was being sent to the ER for evaluation due to hitting his head, however, there is no intervention listed when he came back from the hospital on 8/17/21 but in IDT meeting a fall mat was placed. Further, RN-A referring to fall on 8/18/21, stated the immediate intervention was gave call light, bed lowered, mat of floor and educated to use the call light. IDT met that day and there was no new intervention stated we just talked about proper footwear, clutter in room and reeducation to use the call light. Referring to the fall on 8/19/21, RN-A stated R1's immediate intervention was R1 was sent to the ER and returned on 8/20/21, there was nothing new put into place after discovery that R1 had a hand fracture. Referring to two falls on 8/23/21, the first one R1 had got outside and fell in the grass with an immediate intervention of R1 being sent to the ER for further evaluation and upon return was found on the floor in his room. RN-A stated nothing new for interventions. IDT meeting regards to both elopement and fall was a stop sign was placed in room, call light was switched to a flat button. It's a touch pad for when he rolls. At this time, RN-A and surveyor went to R1's room to look at the flat button call light. RN-A stated I have not seen one like it, it is new to myself and I am not sure if they [staff] have used it before. It is not an alarm or anything like that. RN-A correctly placed call light which appeared to be the shape of a teepee on top of R1's mattress and the button of the call light was to be placed on the side closest to the resident, not hanging off the bed and upside down like previously observed. RN-A stated she was not sure if the staff have been trained on how to properly place the flat button call light. During interview on 8/27/21, at 11:13 a.m. with the Director of Nursing (DON) when asked what the facility procedure was for a fall, the DON stated staff should check the room, check the situation wherever they fall to make sure nothing is out of place. Assess the situation and resident and put a new intervention if there is a new one. There is not always a new intervention, there is only so much you can do. Sometimes all you can do is reeducate. Further, DON indicate IDT meet the next business day review it [fall] again and determine a root cause, if we [staff] determine one, address that issue and go from there and care plan it. When going through R1's 11 falls since admission, DON stated we are doing the IDT and we are doing the things like basic root cause analysis, but we are not documenting it. But it should absolutely be on the care plan and it should be documented in IDT. DON also confirmed the same information as RN-A had. In addition, DON stated staff were expected to check on [R1] more frequently and think outside of the box if they can't think of a new intervention after a fall. If they [staff] can't think of a new intervention, then more frequent checks and remind him to use the fall light if there is a fall with injury they call the directors otherwise we review it in IDT. Further, DON stated after the fall on 8/23/21, a flat call light was placed because he would be more likely to slap than squeeze. We trained staff on the call light. I understand NA-B said it was a bed alarm. I am not sure if [staff] have used this call light here before. Not all staff were educated on the call light. At approximately 2:38 p.m. DON stated R1's cognition is not good. I don't think he [R1] would be able to use his call light consistently. I think for the most part he knew what it was for, but I can't say that 100 percent of the time he would use it if he needed to. I think it's important to keep trying so it become engrained, and they understand that. On 8/27/21, at 3:21 p.m. administrator stated, after a fall we [staff] get together a root cause analysis and put interventions during IDT and keep putting interventions in place if the family agrees to the interventions. Further, administrator stated, it is hard to determine the root cause with dementia. Administrator stated R1's BIMS [brief interview for mental status] was low but he was still able to say what he needed and what he wanted. [R1] is able to use a call light. We [staff] were rounding on him frequently because he would not know he put on the call light and that is why he has a touch pad call light. We trained staff to the call light however, the older staff thought it was an alarm pad because they look very similar. Every single nursing staff that worked from my understanding was aware. He moved from one unit to the other to have better eye on him and I am unsure if all staff were cross trained in that form. On 8/30/21, at 4:52 p.m. Administrator provided surveyor with a toileting program R1 started on day of admission 7/21/21, to determine how often they [residents] go to the bathroom. However, the information did not affect R1's falls and no interventions were added from the results of the toileting program. Administrator also provided surveyor with results of R1's sleep watch which determined R1 was not sleeping much. Administrator stated, we tried to adjust his bedtime and no napping during the day trying to get the restful sleep to prevent falls but none of it worked. However, that had not been communicated to the rest of the staff and was not in R1's record. Review of facility policy titled Fall Prevention Program Policy dated 6/1/21, indicated if a resident is determined a high risk the resident will be placed on the facility's fall prevention program. In addition, residents will be provided interventions that address unique risk factor measured by the risk assessment tool: medications psychological, cognitive status, or recent change in functional status. As well as provide additional interventions as directed by the resident's assessment. Further review of policy, each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: interventions will be monitored for effectiveness, and the plan of care will be revised as needed. In addition, when any resident experiences a fall, the facility will assess the resident, complete a post fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the care of injury. The IJ which began on 8/17/21, was removed on 8/31/21, at 5:06 p.m. after the facility successfully implemented a removal plan which included the following: -R1's care plan was revised for at risk for falls with a new intervention that included the facility will collaborate with family to provide 1-1 supervision. the facility will re-evaluate the 1-1 status upon readmission to facility after comprehensive assessments are completed. -IDT completed a root cause analysis for all 11 of R1's falls. -Education was provided to staff related to resident who have a BIMS score of 12 or lower and a list of examples provided to staff that would be appropriate interventions to implement after a fall. -Education provided to all licensed nursing staff on resident fall prevention program/protocol.

Based on observation, interview and document review, the facility failed to comprehensively assess and monitor pressure ulcers for 3 of 3 residents (R32, R5, R10) reviewed with current pressure ulcers. In addition, the facility failed to implement repositioning interventions for 1 of 1 resident (R32) reviewed with a recurring, worsening stage two pressure ulcer (pressure ulcer partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister.) This deficient practice caused actual harm to R32 when a recurring stage two pressure ulcer worsened and two additional stage two pressure ulcers developed. Findings include: R32's quarterly Minimum Data Set ((MDS) dated [DATE], identified R32 had [DIAGNOSES REDACTED]. The MDS identified R32 was cognitively intact and was dependent on staff for ADL's of transfers, toileting and required extensive assistance with bed mobility, dressing and personal hygiene. The MDS revealed R32 had an indwelling urinary catheter and had occasional bowel incontinence. The MDS identified R32 was at risk for developing pressure ulcers and had one current stage two pressure ulcer. The MDS identified R32 had pressure ulcer prevention interventions in place which included; pressure relieving devices in chair, bed, turn and repositioning program, pressure ulcer care, application of ointments/medications. The MDS identified R32 had no rejection of cares. R32's quarterly MDS dated [DATE], identified R32 was cognitively intact and required extensive assistance with activities of daily living (ADL's) such as bed mobility, dressing and was totally dependent on facility staff for transfers and toileting. The MDS revealed R32 had an indwelling urinary catheter and had occasional bowel incontinence. The MDS identified R32 was at risk for developing pressure ulcers, had no current pressure ulcers and listed the following pressure ulcer prevention interventions were in place; pressure relieving devices in chair, bed, turn and repositioning program, nutrition and application of ointments/medications. The MDS identified R32 had no rejection of cares. R32's annual Care Area assessment dated [DATE], identified R32 was cognitively intact and required extensive assistance with ADL's of bed mobility, transfers, toileting repositioning. The CAA revealed R32 was at risk for developing pressure ulcers, and had no current pressure ulcers. The CAA revealed R32 refused a breathing treatment, however the CAA did not identify R32 refused cares. R32's Resident Temporary Care Plan dated 8/13/19, revealed R32 had a 2.0 centimeter (cm) by 0.1 cm open area on her left posterior thigh, continue current treatment, monitor twice daily (bid,) proper placement of catheter tubing and indicated R32's primary care physician had been notified along with the director of nursing. R32's care plan reviewed 10/15/19 , revealed R32 was dependent on staff for transfers with a mechanical lift, toileting and personal hygiene. The care plan revealed R32 had a history of [REDACTED]. R32's care plan indicated she often declined offloading, laying down, and repositioning. R32's care plan revealed she was aware of risk for worsening ulcers. R32's care plan listed various pressure ulcer interventions which included; encouraging every hour repositioning and explaining importance of repositioning, pressure reducing cushion, pressure relieving mattress, position catheter strap on left leg and apply soft cotton sleeve over tubing to protect skin. R32's nursing assistant care guide dated 9/4/19, identified R32 was to be assisted to reposition every hour. R32's Braden Scale For Prediction of Pressure Sore Activity (tool used to identify risk for pressure ulcer development based on mobility, nutrition, moisture, friction and shearing) dated 7/8/19, identified R32 was at risk for pressure ulcer development and identified R32 had the following interventions in place; pressure relieving device for chair and bed, turning and repositioning program, nutrition interventions and applications of medications /ointments. R32's Braden Scale For Prediction of Pressure Sore Activity dated 10/7/19, identified R32 was at risk for pressure ulcer development and identified R32 had the following interventions in place; pressure relieving device for chair and bed, turning and repositioning program, nutrition interventions and applications of medications /ointments. R32's medical record was reviewed from 12/1/2018, to 10/22/2019, R32's medical record lacked any comprehensive skin assessments for the chronic left posterior thigh recurring stage two pressure ulcer and further development of additional pressure ulcers. There was no indication the facility assessed the stage, description and characteristics of the PU, progress toward healing, if infection or pain was present nor was there a description of the dressing and/or treatments. On 10/21/19, at 2:00 p.m. R32 was lying in bed on her back, eyes were closed, she was covered with a blanket up to just below her chin. On 10/21/19, at 3:48 p.m. R32 was seated in a cushioned wheelchair in her room. At that time R32 stated she had a few sores on her buttocks for the last six months or so. She indicated she had had the sores on her buttocks in the past and at one time she had required a [DEVICE] (wound treatment device that used negative pressure to the wound to aid in healing.) R32 stated she understood the sore on her buttocks were pressure ulcers. She indicated at that time, staff were applying cream to her buttocks and she was supposed to be repositioned every two hours. R32 stated the facility staff did not routinely offer to reposition her and indicated the facility staff never repositioned her every hour. R32 indicated she did not ask facility staff to reposition her as she felt the staff had other residents to care for. On 10/21/19, at 5:48 p.m. R32 was seated in a wheelchair in the dining room at a squared table with three other residents. R32 stated she had been up in her wheelchair since the last time she was interviewed, at 3:48 p.m. R32 stated she had not been offered to reposition and had not asked staff to reposition her. Review of R32's nursing progress notes from 7/10/19, to 10/22/19, revealed the following: -7/10/19, no pressure ulcers though had treatment in place for area on posterior left thigh. A later note revealed R32's skin on her upper left posterior had areas which were not blanchable (indicative of a stage one pressure ulcer.) -7/18/19, left buttocks area was red, raw and cream was applied. -7/25/19, currently had an open area on her left thigh, indicated area was old and had no other skin issues. The note lacked any further characteristics of R32's open area. -8/8/19, left buttocks area was red, raw and cream was applied. -8/13/19, a 2 cm by 0.3 cm open area on left posterior thigh. The note revealed R32 had skin breakdown in the same site previously and appeared to be caused by catheter tubing. R32's progress note indicated to current treatment and monitor twice daily. The note lacked any further characteristics of R32's open area. -8/29/19, left buttocks area was red, raw and cream was applied. 5/19 -9/5/19, current open area on her left posterior thigh with current treatment in place. -9/19/19, had an old open area on her left buttocks and was being monitored. -10/3/19, had an old open area on buttocks and had monitoring in place. -10/9/19, had an open area on left posterior thigh, measured 2.0 cm by 0.3 cm, treated with skin prep, Dimethicone cream and [MEDICATION NAME] daily. The note lacked any other characteristics of R32's stage two pressure ulcer. -10/14/19, had a stage two pressure ulcer to her left posterior thigh. A later note revealed R32 stage two pressure ulcer measured 2.0 cm by 1.0 cm by 0.5 cm and had a second open area which measured 0.5 cm by 0.5 cm above the other open area. The note indicated the current treatment was to clean area with wound cleanser, apply skin prep, Dimethicone 5% daily and cover with [MEDICATION NAME]/Opsite dressing. The note revealed the open area would improve and worsen when R32 refused to lay down and reposition throughout the day. R32's progress notes lacked any further documentation of the three stage two pressure ulcers and lacked any documentation of R32 refusing repositioning or cares. On 10/23/19, during continuous observations from 7:08 a.m. to 8:59 a.m. the following was observed; -at 7:08 a.m. R32 was lying in bed on her left side while nursing assist (NA)-assisted her with morning cares. R32 had three open areas on her left intertrochanteric area (posterior junction of the buttocks and thigh,) and the surrounding skin was raw and reddened. Licensed practical nurse (LPN)-C entered R32's room and proceeded to complete wound care to R32's open areas. LPN-C stated R32's open areas were pressure ulcers and indicated R32 had recurring pressure ulcers on her left intertrochanteric area. NA-B and LPN-C proceeded to assist R32 up into her wheelchair. -at 7:16 a.m. R32 was seated in a wheelchair and was wheeled to the dining room by NA-B. -at 7:55 a.m. R32 remained seated in a wheelchair in the dining room, ate her breakfast independently and conversed with her three tablemate's. -at 8:27 a.m. R32 remained seated in a wheelchair in the dining room and proceeded to propel herself out of the dining room, towards her room. At that time, NA-D offered to assist R32 to her room. NA-D wheeled R32 to her room, asked R32 if she needed anything and left her room. NA-D did not offer or encourage R34 to reposition. -at 8:44 a.m. R32 remained seated in a wheelchair in her room positioned in front of her television. R32's eyes were open and actively watched the television. -at 8:59 a.m. R32 remained seated in a wheelchair in her room. NA-D and NA-C entered her room with a full mechanical lift and proceeded to assist R32 out of her wheelchair and onto her bed. R32 was positioned on her back, covered with a blanket up to her upper chest, call light was given to her and the room lights were shut off. R32 had remained in a seated position for a total of 1 hour and 51 minutes, without being offered or encouraged to reposition. On 10/23/19, at 9:23 a.m. NA-B stated R32 was totally dependent on staff for transferring to and from her bed to her wheelchair. NA-B stated R32 had a current pressure ulcer and indicated R32 had a previous pressure ulcer in the same area, at the junction of the buttocks and thigh on her left side. NA-B stated R32 required every hour repositioning and would oftentimes refuse to change position. NA-B stated she had not offered to reposition R32 since she had assisted her up that morning a few hours previously and indicated she would wait until R32 requested to be repositioned. NA-B stated she felt R32 had a long history of refusing to reposition every hour, and she had been assisting other residents with cares and eating. On 10/23/19, at 1:41 p.m. R32 was seated in a wheelchair in her room, positioned in front of the television with the television on. R32 stated she had not been offered to reposition by a staff member that day and had not refused to be repositioned. On 10/24/19, at 8:36 a.m. NA-D stated R32 was totally dependent for repositioning and was able to ask for assistance with repositioning. She indicated she felt R32 had a long history of having open areas to her left posterior thigh/buttocks area and refused routine repositioning. On 10/24/19, at 8:45 a.m. R32 was lying in bed on her back, her eyes were open. At that time, the director of nursing (DON) entered R32's room, confirmed R32 had three stage two pressure ulcers. She stated she was not aware R32 had developed a third pressure ulcer and confirmed R32 had two stage two pressure ulcers when she last measured on 10/14/19. The DON proceeded to measure R32's three stage two pressure ulcers; -stage two pressure ulcer measured 2.0 cm in length, 1.0 cm in width and 0.5 cm in depth and had minimal granulation tissue, (beefy red, granular in appearance tissue.) -stage two pressure ulcer above the above area, measured 0.5 cm by 0.5 cm by 0.5 cm, with minimal granulation tissue. -stage two pressure ulcer to the right of the above area, measured 0.5 cm by 0.5 cm, was unable to measure depth. DON confirmed R32 had three stage two pressure ulcers on her left posterior thigh/buttocks. The DON confirmed R32 had one stage 2 pressure ulcer which had completely healed in (MONTH) of 2019, and had recently re-opened when the tubing of her catheter had caused pressure on R32's posterior left thigh/buttocks area. The DON confirmed R32 had recently developed the third stage two pressure ulcer since she last measured on 10/14/19. On 10/24/19, at 9:00 a.m. The DON confirmed she had not been aware of the development of a third pressure ulcer for R32, and confirmed R32's three stage two pressure ulcer had not been comprehensively assessed and had not been routinely measured to monitor for healing. The DON stated the facility did not have enough licensed staff to routinely monitor resident skin condition and complete comprehensive assessments, which included R32's comprehensive pressure ulcer assessment. She indicated she was unable, due to lack of licensed staff, to routinely monitor residents skin conditions to monitor for healing and/or worsening. The DON indicated, at that time, she was solely responsible for the completion all residents comprehensive assessments. She indicated The DON stated R32 had a long history of pressure ulcers to her left posterior thigh and had utilized a wound vac in the past to heal the pressure ulcer. The DON stated R32 should be offered to reposition every hour to hour and a half. She indicated R32 had a history of [REDACTED]. On 10/24/19, at 9:34 a.m. a telephone interview was conducted with R32's primary physician (MD)-[NAME] MD-A stated R32 had a chronic pressure ulcer on her left posterior thigh/buttocks area and indicated he expected the facility staff to follow all pressure relieving interventions. He indicated due to the chronic nature of R32's pressure ulcer, he felt repositioning her every hour was the last line of defense against the pressure ulcers from worsening. MD-A stated he would have expected to be notified when R32's pressure ulcer worsened in size and when the other areas developed. He indicated he felt a change in R32's dressing change should have been done when the new stage two ulcers developed. R32's physician orders signed 10/17/19, revealed the following wound care orders: - order with a start date of 5/11/17, to cleanse R32's left posterior thigh area with wound cleanser, apply skin prep and Dimethicone 5% to upper left thigh daily and as needed. Apply Opsite/[MEDICATION NAME] (occlusive wound dressings,) restarted 10/16/17. -order with a start date 8/24/17, No Sting Skin Prep to left posterior thigh Twice Daily. R32's physician Communication form dated 8/13/19, revealed R32 had an open area on posterior left thigh measuring 2.0 cm by 0.3 cm, appeared to be from catheter tubing, current treatment in place of wound wash, no sting skin barrier and Remedy twice daily. The form revealed R32's practitioner responded on 8/15/19, per above, use catheter secure device to prevent movement or pressure. R32's physician progress notes [REDACTED]. R32's physician progress notes [REDACTED]. The note lacked any information on R32's chronic left posterior thigh skin ulcer. Review of the facility policy titled, Pressure Ulcer Treatment dated 12/3/17, identified how to assess the pressure ulcer for location, size, sinus tracts, undermining, tunneling, drainage, necrotic tissue and presence or absence of granulations tissue. The policy identified the definitions of the four stages of pressure ulcers and instructed staff to document in the medical record all of the assessment data obtained when inspecting the ulcer. R5 R5's annual Minimum Data Set ((MDS) dated [DATE], indicated R5 had moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS identified R5 required extensive assitance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. The MDS indicated R5 had been at risk for developing pressure ulcers and currently had no pressure ulcers. Further, the MDS indicated R5 had a pressure reducing device for her bed and chair and was on a turning and repositioning program, received pressure ulcer care, and applications of dressings and ointments. R5's annual Care Area Assessments (CAA) dated 8/1/19, identified R5 required moderate to maximum assistance with dressing, locomotion and transfers related to weakness, pain and limited range of motion. The CAA indicated R5 had been admitted to the facility with pressure area and sores. The CAA further indicated R5 had been placed on a two hour repositioning and toileting schedule and R5 had been encouraged to sit no longer than 45-60 minutes at a time. R5's care plan revised 8/7/19, identified R5 had an unstageable pressure ulcer that had been present on admission. The care plan instructed staff to monitor and report changes in skin condition daily with cares and weekly with R5's bath and as needed. The care plan further instructed staff to encourage R5 to limit sitting time to 45-60 minutes and to encourage R5 to turn and reposition every two hours. Additionally, the care plan instructed staff to follow facility wound protocol as needed. R5's medical record lacked any Braden, any comprehensive assessment of the unstageable pressure ulcer, and lacked documentation of ongoing monitoring of R5's pressure ulcers. On 10/23/19, at 8:01 a.m. R5 was seated in her recliner in her room, and nursing assistant (NA)-A and trained medication aid (TMA)-A entered R5's room to provide morning cares. NA-A and TMA-A assisted R5 to wash her face and upper body, then proceeded to transfer her to the toilet in the bathroom. At 8:16 a.m. R5 was lifted off the toilet with the use of the standing lift and peri cares were provided to R5. An intact Allevyn dressing was noted to R5's right buttock and thigh area. TMA-A applied R5's pants and assisted NA-A to transfer her into her wheelchair. NA-A assisted to comb R5's hair and proceeded to wheel R5 to the dining room to have breakfast. On 10/23/19, at 10:48 a.m. R5 was lying in bed on her left side with licensed practical nurse (LPN)-A present in her room. LPN-A removed the old dressing present on R5's IT area and described the pressure ulcer as having yellow slough present in the wound bed and indicated she felt it was a stage two or three pressure ulcer. LPN-A measured the pressure ulcer and it measured 2 cm. by 3.0 cm. LPN-A described the perimeter of the wound as pink tissue present. At 10:53 a.m. LPN-A cleansed the wound bed with the wound cleanser and applied the skin prep to the perimeter of the wound. LPN-A then applied the Santyl ointment to the wound bed followed by the 5 by 5 Allevyn dressing over the wound. On 10/21/19, at 2:46 p.m. R5 stated she had the pressure ulcer present on her right IT prior to admission and indicated she understood it had improved. R5 stated the nursing staff completed daily dressing changes to the pressure ulcer and encouraged her to reposition every two hours when in bed and more often when up in her recliner. R5 stated she had a special cushion in her recliner and had a special pressure reducing mattress in her bed. On 10/23/19, at 1:37 p.m. LPN-A stated she believed R5's pressure ulcer was a stage two pressure ulcer. LPN-A stated it was expected the nurse who completed the dressing change to R5's pressure ulcer documented on the treatment assessment record (TAR) and the progress notes. LPN-A stated the skin inspections were completed weekly on bath days by the bath aid. LPN-A stated she went by what was documented on the bath aid sheet unless she was aware there was already something present out of the ordinary such as a bruise or a wound. LPN-A reviewed R5's medical record and confirmed the medical record lacked weekly pressure ulcer evaluation and monitoring of R5's pressure ulcer. On 10/24/19, at 9:01 a.m. registered nurse (RN)-A indicated R5 was admitted to the facility with an unstageable pressure ulcer present on her right IT. RN-A stated the WCN followed R5 for her pressure ulcer care every other week. RN-A further stated the licensed nurse assigned to medications and treatments for R5's unit would be responsible for completing the weekly evaluation and monitoring of R5's pressure ulcer. RN-A reviewed R5's medical record and confirmed pressure ulcer evaluation and monitoring had not been completed for R5. Review of R5's facility form titled Minnewaska Lutheran Home Admission Skin Condition dated 7/19/19, indicated R5 had an open area to her right buttock which measured 6.5 cm. by 4 cm., a second to her right buttock which measured 3 cm. by 2 cm. and a third one to her right buttock which measured 0.6 cm. by 1 cm. Review of R5's progress notes from 7/19/19, to 10/23/19, revealed the following: -7/19/19, R5 was admitted to the facility. R5 had two open areas present on her right buttock that measured 6.5 cm. (centimeters) by 4 cm. and 0.6 cm. by 1 cm. -7/22/19, R5's first pressure ulcer measured 6.5 cm. by 4 cm. and had a black area in the middle that measured about the size of a quarter. R5's second pressure ulcer measured 0.6 cm. by 1 cm. -7/25/19, dressing change had been completed to R5's pressure ulcers. The wound bed was noted to be covered in white slough. -7/26/19, the wound care nurse (WCN) had assessed R5's pressure ulcers and made recommendations to keep R5's head of bed elevated 30 degrees to reduce friction/shear and to have R5 lay side to side when in bed. Further, the WCN indicated R5's dressing changes were to include cleansing the areas with wound cleanser, applying 3M no sting barrier film around the perimeter of the pressure ulcers and apply Allevyn 5 by 5 dressing over the area. -7/27/19, dressing change had been completed to R5's pressure ulcers and less slough had been noted to the wound bed. -7/29/19, dressing change had been completed to R5's pressure ulcers. -7/31/19, R5's pressure ulcer to right ischial tuberosity (IT) (sitting bones) measured 2.7 cm. by 6.0 cm. and an area of yellow slough in the wound bed measured 1.8 cm. by 4.0 cm. -8/8/19, seen by WCN, indicated R5's right IT pressure ulcer measured 2.7 cm. by 6.0 cm. and the area of white slough measured 1.6 by 4.0 cm. The WCN indicated the slough was much thinner than the previous time she assessed the wound however indicated there were still areas of thick slough. -8/14/19, seen by WCN, recommended change of treatment plan to clean right IT with wound cleanser apply 3M non-sting barrier skin prep to the perimeter of the wound, apply Santyl (an ointment used for [MEDICATION NAME] pressure ulcers) ointment and cover 5 by 5 Allevyn dressing. -8/28/19, seen by WCN, recommended to continue with the current treatment plan. -9/11/19, seen by WCN, recommended to continue with the current treatment plan. -9/25/19, seen by WCN, recommended to continue with the current treatment plan. -10/10/19, seen by WCN, recommended to continue with the current treatment plan. -10/23/19, the dressing change had been completed to the right IT. The open area (including the reddened perimeter) measured 2 cm. by 3.0 cm. The progress notes lacked documentation of ongoing pressure ulcer evaluation which included signs of infection, stage, size and characteristics of R5's pressure ulcers. On 10/24/19, at 11:13 a.m. WCN stated she followed R5 for her wound cares every other week and confirmed R5 currently had a unstageable pressure ulcer. The WCN indicated she felt R5's pressure ulcer to her right IT had improved since admission. The WCN stated it was expected R5's pressure ulcer was assessed and monitored weekly. The WCN further stated she was not certain who was responsible for the pressure ulcer assessments and monitoring of the pressure ulcers on the week she was not in the facility. On 10/24/19, at 1:22 p.m. the DON stated it was expected pressure ulcers were assessed and monitored at least weekly. The DON stated the licensed staff assigned to R5's unit to administer medications and treatments were responsible for the weekly assessments and monitoring of R5's pressure ulcer. The DON reviewed R5's medical record and confirmed R5 had not had any comprehensive assement completed, and confirmed ongoing monitoring of R5's pressure ulcer had not been completed. Review of the facility policy titled Pressure Ulcer Treatment dated 12/3/17, identified how to assess the pressure ulcer for location, size, sinus tracts, undermining, tunneling, drainage, necrotic tissue and presence or absence of granulations tissue. The policy identified the definitions of the four stages of pressure ulcers and instructed staff to document in the medical record all of the assessment data obtained when inspecting the ulcer. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2018, identified Section M: Skin Conditions to be completed to identify the risk, presence, appearance and change of pressure ulcers/injures. The manual defines a pressure ulcer/injury as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure in combination of shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The manual further identified it was imperative to determine the etiology of all wounds and [MEDICAL CONDITION] as that would determine and direct the proper treatment and management of the wound. - The manual defines an unstageable pressure ulcer/injury as Known but not stageable due to coverage of wound bed by slough or eschar. R10 R10's quarterly MDS dated [DATE], indicated R10's [DIAGNOSES REDACTED]. The MDS indicated R10 had severe cognitive impairment and required extensive assist from 2 staff with dressing, toileting, personal hygiene, transfers, and was dependent on staff for locomotion on and off the unit. The MDS indicated R10 had no pressure ulcer or skin conditions, including venous or arterial wounds. R10's annual Care Area Assessment (CAA) dated 8/5/19, identified R10 was at a moderate risk for developing pressure ulcers, and indicated R10 had no pressure ulcers at that time. The CAA did not list any current interventions but indicated the facility would continue with the current plan of care. R10's care plan dated 8/8/19, indicated he was at high risk for the development of pressure ulcers related to staff dependence with activities of daily living (ADL)s and transfers. The care listed various interventions which included pressure reducing mattress, Podus boot to right foot while up, and off load heels while in bed with bilateral heel protectors, repositioning every 2 hrs and as needed, and instructed staff to monitor and report changes in skin condition daily, with cares, weekly with bathing, and as needed. On 10/23/19, at 7:20 a.m. R10 was observed lying in bed, with licensed practical nurse (LPN)-A present in the room. LPN-A removed a black padded boot from R10's left foot, and a yellow stained undated dressing of 2X2 gauze with paper tape was observed on R10's heel. LPN-A stated she was not aware of any skin issues with R10's heel, and did not know why he had a dressing on his heel. LPN-A verified the dressing was undated, and removed the soiled dressing. A thick, blackish brown scab was observed on the posterior left heel. LPN-A stated she had been unaware R10 had a current pressure ulcer, and described the pressure ulcer as a scabbed area was brown, black eschar and described it as an unstageable pressure ulcer on the posterior of R10's heel. LPN-A stated she had never provided any treatments or monitoring to R10's heel. LPN-A stated R10 wore black boots on his feet to relieve pressure due to being a high risk for break down and required repositioning every 2 hours. LPN-A stated she thought the [MEDICATION NAME] order was for a scab on the toe of his left foot, not his heel. LPN-A verified there was no monitoring for R10's heel in the treatment administration record (TAR) other than the order to apply [MEDICATION NAME] twice per day. On 10/23/19, at 9:14 a.m. nursing assistant (NA)-G stated R10 has had a scabbed area on his left heel for as long as she could remember and stated he used boots to relieve pressure on his heels. On 10/23/19, at 9:54 a.m. registered nurse (RN)-A stated she recalled R10's heel scab as being a dry thick brown black eschar area, and indicated it was an unstageable pressure ulcer at that time. RN-A stated she had seen a scabbed area on the posterior of R10's left heel about a week ago, but indicated she did not document, measure it, or complete an assessment of it and indicated that was usually done on different shift. RN-A stated that nursing staff applied [MEDICATION NAME] to the area twice per day and R10 heel, and stated there should be progress notes, but verified she did not find any in R10's EMR. She stated the usual process for the ongoing monitoring for pressure ulcers would be to document the measurements and assess the wound at least weekly. RN-A stated the treatment and monitoring of the pressure ulcer should be documented in the electronic medical record (EMR), and included in the progress notes. RN-A stated if an area was a long standing ongoing issue without significant improvement she would update the provider to see if there are other treatments that could be tried. R10's medical record lacked documentation of a comprehensive skin assessment completed from 6/13/19, to 10/23/19, and R10's progress notes revealed the following: - 6/13/2019, noted a scabbed area on his left heel, and indicated treatment and monitoring was in place. - 7/31/2019, identified a scabbed area on R10's left heel measuring 1.1 centimeters (cm) by 0.8 cm that was swabbed with [MEDICATION NAME] twice a day, and indicated the area was dry with no drainage, redness, swelling, or any other signs/symptoms of an infection. - 8/12/19 R10 was hospitalized for [REDACTED]. - 8/20/19, a nurses baseline readmission information and temporary care plan was completed and identified skin was pale, dry, warm and a raised scab area on R10's left heel measuring 1 cm by 1 cm by 0.2 cm. The note lacked any further information regarding R10's left heel. In addition, the medical record lacked any notification to the provider of R10's left heel scab noted on readmission to the facility. - 9/26/2019, noted old scabbed areas on (L) heel, and indicated R10 had no open areas or other skin issues. - 10/17/2019, after R10's bath it listed left heel scab was intact with no signs of infection. The progress notes lacked documentation of ongoing pressure ulcer evaluation which included identification, monitoring, stage, measurements or characteristics of R10's pressure ulcer. On 10/23/19, at 10:33 a.m. the director of nurses (DON) stated RN's were re (TRUNCATED)

Based on interview, and document review, the facility failed to provide the necessary care and services for 1 of 1 resident (R1) whose mental status declined and began refusing cares, medications and was having uncontrolled behaviors. In addition, R1 developed pressure ulcers, and weight loss due to refusals. The deficient practice resulted in psychosocial harm for R1 when the facility failed to intervene timely when R1 experienced increased behaviors, increased refusals of toileting, incontinence care, and meals with signifacant weight loss, development of stage 2 pressure ulcers and required hospitalization . Finding include: R1's quarterly Minimum Data Set (MDS) dated , 11/1/19, indicated R1 had [DIAGNOSES REDACTED]. The MDS indicated R1 had moderate cognitive impairment and required extensive assistance for transfers, toilet use, dressing and personal hygiene. The MDS also indicated R1 was always incontinent of urine and bowel, had no toileting program and was at risk for pressure ulcers. The MDS further indicated R1 had no mood or behavior disorders and had received anti-psychotic and anti-depressant medication in the last seven days. The MDS also indicated R1's current weight was 189 pounds, no signs and symptoms of swallowing disorder, no weight loss or weight gain, and received a mechanically altered diet. R1's discharge MDS dated [DATE] indicated R1's was moderately impaired for daily decision making, had continuously disorganized thinking and altered level of consciousness. The MDS also indicated R1 had physical and verbal behaviors towards others, rejection of cares occurred 4 to 6 days. The MDS further indicated R1 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, total dependence for bathing and was always incontinent of bowel and bladder. Further, the MDS indicated R1's current weight was 166 pounds. Review of R1's care plan, revised 11/8/18, indicated R1 was receiving [MEDICAL CONDITION] medications due to [DIAGNOSES REDACTED]. The care plan indicated R1 refused cares, toileting, incontinence cares, meals and yelled at staff and directed if became violent or physically aggressive, the facility would take specific steps to minimize the risk to residents self and other residents in the facility, visitors and staff and one on one social service visits as needed. The care plan also indicated R1 required extensive assistance of staff for grooming dressing transfers, toileting and bathing, was incontinent of bowel/ bladder. Review of R1's Progress Notes from 11/2/18 to 1/14/18, revealed the following: -11/2/18 , at 3:30 p.m. estimated average intake from all food groups 75 to 100 percent (%), fluid intake with meals, R1 makes food choices known, requesting none of that ground meat, weight 11/1/18 (wt) 186.5, 30 day wt loss 5.7 pounds (2.9%) since 10/4/18. R1 refuses to come to dining room for 5 meals, meal trays were provided to room. -11/5/18 at 2:39 p.m. R1 refused breakfast yelled (leave me alone) and refused to get out of bed until 10:45 a.m. -11/8/18 at 12:17 p.m. R1 refused breakfast, yelled (get out) and refused to get out of bed until 10:45 a.m. -11/13/18 at 12:17 p.m. R1 refused breakfast yelled (leave me alone) and refused to get out of bed until 10:45 a.m. -11/18/18, at 6:52 p.m., pants were soiled with bowel and urine, refused to let staff help him to the bathroom and told them to get out. The notes indicated R1 continued to refuse assistance with incontinence care when staff reproached and at 9:15 p.m., R1 was found on the floor, he had vomited, slipped in the vomit and fallen. -11/19/18, at 9:59 p.m., remained in bed the entire shift, refused to have his soiled brief changed and yelled at staff. -11/20/18, at 4:15 a.m., saturated in urine and bowel, refusing to let staff clean him up, kicking, punching, yelling at staff and told them to get out. At 12:11 p.m. refused to get up for breakfast and lunch today and refused to let staff change gown and incontintent brief. -11/25/18, at 9:10 a.m., refused breakfast, his pills and at 9:45 a.m. soaked in urine and bowel from last evening. R1 had bowel on his fingers, refusing cares, changing of clothes and told staff to get out. -11/26/18, at 12:42 p.m., lying in bowel and soiled garments while social worker visited with him about his refusal of cares. -11/27/18, at 1:54 p.m., order received to send to Staples or [MEDICAL CONDITION] Behavioral Health Facility, had multiple behaviors of aggression and refusal, interventions unsuccessful. At 4:13 p.m., R1's brother updated on recommendations for R1 to be seen at Staples or [MEDICAL CONDITION] Behavioral Health Facility and was told the facility had not contacted either facility yet to see if they have an open bed. At 9:52 p.m. refused supper, toileting and to be changed on night shift. -11/29/18, at 9:18 p.m., visibly soiled, while staff tried to help he became agitated, grabbed, kicked staff, ripped off his brief and refused cares. -12/1/18, at 5:57 p.m., R1 refused to be changed or toileted, washed up and night time cares. -12/3/18, at 6:07 a.m., R1 undergarments were soiled, starting yelling and refused cares. -12/5/18, at 1:57 p.m. refused breakfast and lunch and combative with cares. At 8:59 p.m., R1 remained in bed and refused cares all shift. -12/7/18, at 8:59 p.m., R1 refused all evening and night shift pills. -12/9/18, at 4:25 p.m., strong odor of urine and bowel and continues to refuse cares and says leave me alone. -12/10/18, at 4:49 p.m., open area 2 centimeter (cm) by 0.5 cm on right buttocks from refusing to have incontinent brief changed. - 12/13/18, at 6:05 p.m., R1 yelling at staff while getting him ready for the day, placed R1 on the toilet and began to kick his wheelchair forcefully towards staff and staff unable to get R1 completely cleaned up. R1 had bowel on his hands and was kept in his room for lunch due to having bowel on his hands. -12/14/18, at 1:01 p.m., licensed social worker and brother saw R1, he was confused and refused to answer questions about mood or behaviors. The LSW-B sent progress notes and medication list to psychiatric nurse for consult on behaviors. At 2:59 p.m. R1 had refused all cares this shift, medications, breakfast and remained in bed. -12/15/18 at 10:51 a.m., refused to let staff clean him up, in bed and incontinent. Staff tried to educate R1 on skin breakdown and continued to refuse cares. At 9:02 p.m. refused to come for evening, eat and all evening cares. -12/18/18, at 8:27 p.m., R1 had remained in bed and refused all cares. -12/19/18, at 11:13 a.m., open area on coccyx measured 0.75 centimeter (cm) x 0.2 cm, and complained of pain while staff wipe off bowel from buttocks and applied protective cream. At 10:00 p.m., refused to come out for supper, to have night cares done, clothes to be changed and a clean brief put on, became very combative, agitated and told staff to leave his room. -12/22/18, at 1:00 p.m., refused cares, vitals and medications. At 9:23 p.m. refused to be changed, evening cares, supper and vital signs. -12/23/18, at 12:38 p.m., refused cares, medications, food and repositioning. At 1:50 p.m., was washed up, changed and bedding changed with the assistance of four staff members while he proceeded to kick, hit, grab, punch and bite staff after refusing cares for two days. At 2:41 p.m., refused breakfast and dinner today, had aggressive and physical behaviors towards staff, continued to refuse morning cares, peri cares, repositioning and medications. The smell of urine was quite pungent in R1's room, spoke with R1's brother today about behaviors and brother indicated he wanted to speak to someone about becoming R1's power of attorney and social service designee (SSD) was notified. Discussed pending order for Staples evaluation with brother and R1, indicated R1 may need to go there. Staff indicated R1 was a safety risk not only to himself, but to staff, other residents and staff questioning R1's cognition comprehension of situation. -12/25/18, at 9:54 a.m., 20 behaviors in the past week, has refused cares, food, medication and has been verbally and physically aggressive towards staff. Calm approach not effective, reproaching not effective, continue to monitor. - at 4:49 p.m., refused cares and to get up all day, hit and kicked at staff, refused dressing on buttocks, refused vitals, refused repositioning and changing of brief all day. Calm approach and reproach not effective. -12/29/18, staff entered room at 9:45 a.m. and R1 had large incontinent bowel movement and was incontinent of urine in bed. R1's bed was urine soaked due to R1 refusing cares through out the night. Three staff assisted R1 to the toilet while R1 was hitting and kicking at staff while trying to remove his soiled clothes and incontinent brief. Staff attempted to clean bowel from R1's back, legs, buttocks and lower extremities while R1 continued to hit and swing at staff. R1 was transferred via mechanical lift back to his wheelchair while hanging in the sling after refusing to hold onto the handle and stand up on the mechanical lift. R1 continued to kick at staff while they cleaned up bowel and urine off the floor, his bed/ bedding and clothing with the assistance of 3 staff due to R1 behaviors. -12/30/18, at 8:49 p.m., refused to take medications after staff asking if he would like assistance, yelled at staff no, get out of my room, and staff left room. -12/31/18, at 12:41 p.m., refusing all cares and morning medications. At 2:51 p.m. staff entered room attempted to change R1 due to being incontinent of bowel and bladder. Staff approached R1, he began to hit at staff with closed fist and kick at them and stated you touch me and your dead. Staff were able to remove incontinent white pad from under him, but was unable to change R1 incontinent soiled brief. R1 brother updated on increased behaviors such as hitting, kicking, being verbally abusive towards staff and refusing meals. Staff indicated to R1 brother that R1 may need to go for inpatient medication review due to his behaviors. -1/1/19, at 12:14 p.m., refusing to get cleaned up to have dinner with family while striking out with closed fists and refused medications. At 2:02 p.m. registered nurse (RN)-A visited with R1's family and they agreed R1 needed to go some place to help with his behaviors. RN-A asked if they wanted to send R1 to [MEDICAL CONDITION] or Staples, family indicated they wanted R1 to go to [MEDICAL CONDITION] and RN-A indicated she would keep them updated on placement. At 8:41 p.m., R1 refused supper, cares, and medications. -1/2/19, at 4:19 p.m., refused breakfast, lunch, cares, medications and dressing change to buttocks. At 10:55 p.m., refused cares, supper and medications. -1/3/19, at 11:11 a.m., 0.2 cm open area to upper left coccyx and right side of coccyx had an open area that measured 1.2 cm x 0.3 cm and a scoop shaped area measuring 1.5 cm x 0.2 cm, resistive with having area cleaned. At 11:24 a.m., SSD contacted the Senior Behavioral Health to start the referral process, faxed requested information and waiting to hear back from facility if they are able to accept R1. -1/4/19, at 10:30 a.m., communication received with statement related to need for emergency guardianship so R1 can get treatment for [REDACTED]. SSD indicated she would find out from Senior Behavioral Health if guardianship was necessary to transfer R1. Court administrator called and gave number for attorney assistance if needed. At 9:19 p.m., refused cares, medications, liquids and supper. -1/5/19, at 3:49 p.m., combative with cares, striking out at staff and refusing medications, all meals this shift, repositioning and no day shift cares were performed as well today. -1/6/19, at 3:04 a.m., refusing all cares, became very angry, combative and hollering out. - At 8:15 a.m., continues to refuse cares, room very pungent with smell of ammonia from urine and bowel incontinence. Staff report it was intolerable to be in R1's room for more than a few minutes due to smell burning their eyes and creating staff to be nauseated. At 8:30 a.m., room reeks of urine and bowel and R1 was visible soiled as well as bedding with bowel and urine. R1 yelling, hollering, kicking and striking out with attempts to clean up. Pants half way down to his knees and incontinent brief was saturated with bowel and urine. R1 continued to grab, punch, karate chop and kick at staff while trying to change his clothing and incontinent brief. Calm voice not effective Several open areas on coccyx and buttocks, bleeding, appear to have worsened. After cares competed, R1 did not respond to staff and RN-B cleaned the room, opened window for ventilation and sprayed odor eliminator. R1 refused all medications this morning, will continue plan of care. At 9:19 p.m. R1 refused vitals, cares, changing, repositioning, while kicking as staff and unable to redirect. -1/7/19, at 5:58 p.m., incontinent of bowel/bladder, has refused to eat, refused medications and refused cares all day. - 1/8/19, at 8:53 p.m., refused cares, supper and medications. -1/9/19, at 3:56 a.m., soiled with urine and bowel, when staff attempted cares, became very angry and started hitting, hollering, kicking and pinching staff. Staff were able to get him positioned back in bed, but was unable to get R1 to comply with cares. R1 scratched staff arm, drawing blood and broke wrist watch. At 10:54 a.m., refused his medications 5 out of 7 days and R1 has not been taking his [MEDICATION NAME] ([MEDICAL CONDITION] medication). Called pharmacy to get liquid form of [MEDICATION NAME] and it was not available. - At 2:48 p.m. R1 hitting out at staff when cares were being offered this morning and R1 received bruising to left posterior hand, left posterior hand received a skin tear measuring 1 cm x 0.5 cm and scratch measuring 3.5 cm to right posterior hand. - At 4:21 p.m., refused morning cares, meals, medications and continued to refuse all cares this afternoon and R1 remains incontinent of bowel and bladder. Will continue to reproach. - At 8:32 p.m., laying in bed perpendicular, feet on the floor, incontinent brief was off, staff attempted to reposition and R1 attempted to kick staff. R1 refusing to eat or drink and medications this evening. -1/10/19, at 2:21 a.m., R1 refused all cares and tries to hit at staff when cares attempted. At 2:19 p.m., refusing all cares and visibly soiled with bowel and urine, does not have incontinent brief on and refuses all help from staff. Refusing breakfast, lunch, medications and appears to be in pain. - At 3:10 p.m. physicians assistant (PA)-A requested to come and see R1 today due to the urgency of R1's condition. At 3:15 p.m. director of nursing (DON), interim administrator met with R1's brother, expressed R1's choice to be left alone even though soiled with bowel and urine. They explained staff try to assist R1 with cares but he becomes resistive, combative and staff do not want any harm to come to R1, so they leave him and try to reproach. The DON and interim administrator discussed sending R1 to behavioral health center for evaluation because R1 was becoming weaker, refusing food and medications and would not be able to make his own choices. R1's brother indicated that would be fine to see if it would help. - At 6:01 p.m. Office of Health Facility Complaints (OHFC) report filed for issues of self neglect. Refusing to allow staff to perform any cares on him. For the past several hours he has had bowel on his hands, arms, legs and peri area and his bed sheets are smeared with bowel. R1 will hit, and scratch staff when they attempt to clean him up. - At 9:05 p.m. refused to take a shower after 3 attempts and R1 became combative and verbally aggressive. - At 11:05 p.m., continues to refuse cares, meals and medications. LSW-B noted R1 was covered in bodily fluids upon arrival and a vulnerable report will be made to the state. - At 11:09 p.m. seen by PA-A ordered physical therapy to evaluate/treat, complete blood count (CBC), comprehensive metabolic panel (CMP) and urine analysis (UA) to be completed on 1/11/19. Resistive with cares all evening. At 10:15 p.m. police officer had reported to the facility in regards to a welfare check for R1 after a report was made by LSW-B. The police officer and six other staff members entered R1's room and found R1's legs hanging off the bed, no incontinent brief on and covered in bowel and urine as he had refused all cares through out the day. R1 began to holler, punch, kick and scratch at staff while they tried to help in back in bed and get him cleaned up. R1 had multiple open areas on his groin and coccyx area. Staff unable to observe areas due to R1 aggression. -1/11/19, at 10:09 a.m., SSD contacted staff at(NAME)County Adult (PCA) protection and opened an emergency protection case on R1. The staff at PCA protection recommended getting an order to transfer to the emergency room for mental health evaluation and possible 72 hour hold. At 11:20 a.m. DON placed call to the clinic for order for R1 to be sent to the emergency room for mental health evaluation. R1 left the facility via ambulance at 11:15 a.m., combative and resistive with ambulance crew. R1 had not taken medications for 9 out of 14 days. On 1/12/19, at 10:50 a.m., call received from hospital and asking if R1 had any [MEDICAL CONDITION] since admission. The facility staff noted R1 had history of [MEDICAL CONDITION] and reported R1 has had 2 [MEDICAL CONDITION] since his admission to the hospital. Review of R1's physician progress notes [REDACTED]. -11/27/18, indicated R1 had stroke and since coming to the nursing home has had extreme behaviors with physical aggression, frequent falls (4 to 6 times a month), noncompliant with any and all expectations or recommendations. R1 has struck nursing staff personnel, recently tore the skin on one of the staff, has struck another staff in the face with his which was covered with feces and he was currently on antidepressants. The note indicated he posed a danger to himself and the nursing staff and recommended he should be transferred to Staples or [MEDICAL CONDITION] behavioral health facility for care and rehabilitation in the hopes that he can return to his home which was what he wants to do. -1/4/19, recommend an emergency guardianship be granted, due to physical condition deteriorating due to his refusal to accept basic cares form staff and has become physical with nursing staff and had multiple falls. The note indicated it was recommended R1 go to [MEDICAL CONDITION] behavioral health for assessment and management of R1 current medications to try and effect an improvement in his current medical condition. -1/10/19, noncompliant with direction from nursing home staff, combative at time, unwilling to allow assistance in his daily cares and is currently soiling himself in bed with fecal and urine products. Nursing reports this has been a slow progression decline they have been working on getting emergency guardianship but that is not available at this time. Discussed (R1's) current condition with DON, recommend CBC and CMP to further evaluate if there is any metabolic issues that may be playing a role in this. Currently he needs to be working towards a positive outcome, that would include taking his medication which he refuses to do and working with staff on daily cares which he has also refusing to do. The odor in his room was quite pungent obviously of patient having fecal incontinence probably functional and urinary incontinence. Will see how the next 24 hours goes and move forward from there. Also await mental health evaluation. -1/11/19, order to transfer to emergency room for mental health evaluation. During interview on 1/14/19, at 2:10 p.m., nursing assistant (NA)-A confirmed R1 had been extremely aggressive with mood changes and was refusing meals and all cares. NA-A indicated R1's mood and behaviors changed about 3 weeks ago or so and then R1 ended up going to the hospital. NA-A indicated R1 had been punching, kicking, yelling and very aggressive towards staff and family members. NA-A indicated she felt the more staff went into his room the more agitated and upset he got. NA-A indicated R1 used to be able to hold a conversation with others and at present staff could not talk to him without him getting angry and aggressive. NA-A indicated in the past, R1 would always let staff change his brief, toilet him and he always enjoyed his bath time, then all of a sudden he changed. NA-A indicated he stopped communicating with staff, told staff to get out and the more staff tried, the more agitated he got. During interview on 1/14/19, at 2:30 p.m., NA-B confirmed R1 had been refusing cares and would routinely soil himself. NA-B indicated R1 was very angry, would punch and kick at staff and tell staff to get the hell out of his room. She indicated R1 was a very powerful man and when he swung his arms, she would just flinch. NA-B indicated when R1 first came to the facility he was very sarcastic and progressively got worse. NA-B indicated R1 got so bad refusing cares, the odor of bowel and urine permeated all the way down the hallway to the nurses station by the dining room area. NA-B indicated due to R1's continued refusal of cares his bottom was raw and NA-A indicated she did not feel R1 was safe for over a month, had deteriorated and had been refusing his medications as well. During interview on 1/14/19, at 2:36 p.m., LSW-B indicated she started working with R1 in (MONTH) or (MONTH) and at that time R1 was able to visit with her about his history, interests and what he liked or disliked. LSW-B indicated she had discussion with R1 about the issue of women and allowing them to help him. LSW-B indicated she had not seen R1 over the holidays for about three weeks and at that time he was still eating and less reluctant to getting help. LSW-B indicated she seen R1 on 1/10/19, and nursing staff shared concerns that R1 was refusing cares and staff were struggling to take care of him and did not know what to do. LSW-B indicated she went down to R1's room to visit with him after reviewing his chart and you could smell urine and feces outside of his room. The LSW-B indicated she entered R1's room and he had feces and urine all over him. LSW-B indicated she talked with R1 to understand why he was not taking a bath, not eating and he indicated he was weak. LSW-B indicated she could not tell how coherent R1 was during their conversation and indicated R1 was putting his hands in his mouth and by his nose which were soiled with feces. The LSW-B sat down with the DON and interim administrator and discussed her concerns with R1 and told the facility she was going to file a Vulnerable Adult report. The LSW-B indicated they discussed guardianship, 72 hour hold and indicated the PA was in to see R1 but she was not sure if the PA even laid his eyes on R1. The LSW-B indicated R1 was seen by the PA for behaviors and was suppose to be placed in psych unit. LSW-B indicated staff were scared of R1 and indicated she was not contacted of these changes in R1 when he starting refusing all of his cares. During interview on 1/14/19, at 3:43 p.m., NA-C confirmed R1 had been refusing cares and was combative, abusive to staff. NA-C indicated R1 progressively got worse and got the point where he was refusing his medications. NA-C indicated R1 got worse about 3 or 4 weeks ago and then he got really bad in the last week. NA-C indicated it got to the point where R1 would not let staff change his incontinent brief and clean him up. NA-C indicated they were doing whatever R1 would allow them to do or if we could get close enough to do it. During interview on 1/14/19, at 4:35 p.m., RN-A confirmed R1 had been refusing cares and indicated it had gotten worse in the last 6 to 8 days. RN-A indicated R1 would hit, kick and threaten staff. RN-A indicated R1 used to be receptive to staff and had a good rapport with certain staff members and then all of a sudden staff could not do anything for him. RN-A indicated different medications had been attempted and then got an order for [REDACTED]. RN-A indicated the county got involved, filed a report and police came over to the facility regarding R1's cares. RN-A indicated PA ordered R1 to go to the emergency department for a mental health evaluation at that time. During interview on 1/14/19, at 6:07 p.m., DON stated R1 had been refusing cares for a few months and R1 had chosen recently not to let staff help him at all. DON indicated R1 would refuse occasionally at first, and progressively got worse and worse. DON confirmed P-A had written an order to have R1 seen at a behavioral health facility in [MEDICAL CONDITION] or Staples in the past, however, R1's family had not been in agreement to send R1 to a behavioral health facility and R1 did not want to go. DON confirmed R1 had more falls, became more resistive with cares and was not receptive to staff. DON indicated she felt R1 had the choice to refuse care. DON indicated she was aware R1's sister wanted R1 to go to [MEDICAL CONDITION] inpatient care, but understood emergency guardianship was needed and had not heard if the paperwork was filed or not. DON indicated she had been aware of LSW concerns with R1's need for transfer, and confirmed she had not notified P-A of her concerns, but continued to attempt to work on the emergency guardianship with the family. DON confirmed R1 had gone many days without food and medication and felt PA-A would have done more than he did on 1/10/19 when he saw R1. DON confirmed the LSW or SSD had not contacted Staples inpatient mental health facility for placement until 1/10/19. DON confirmed R1 had been sent to the local hospital at that time and had been admitted with breakdown on his buttocks and [MEDICAL CONDITION] activity. Review of R1's emergency room Visit, dated 1/11/19, indicated R1 seldom took his medications, had assaulted staff on at least two occasions, does not often allow staff to evaluate him or clean him and staff concerned he has pressure sores. R1 had progressively more behaviors problems as he was eating less and more and more frequently refusing his medications and has sacral pressure sore stage 1 (persistent redness) mostly with small areas of stage 2 (partial through epidermis). R1 had been admitted to the hospital for evaluation and placement, monitor for [MEDICAL CONDITION]. Review of R1's Discharge Summary, dated 1/18/19, indicated a [MEDICAL CONDITION] had been noted, however, he had not been taking his anticonvulsant's. R1's medications were adjusted, guardian was appointed and arrangements were made for him to go to a nursing home with psychiatric cares in Staples. He will receive routine cares with psychiatric consult to adjust medications. During interview on 1/14/19, at 6:35 p.m., the interim administrator confirmed R1 had been refusing cares and felt he had gotten worse over the last five days before he went to the hospital. Interim administrator indicated the facility's LSW had been working with R1 and had also been seen by PA-A on 1/10/19, and staff were directed to try different approaches and a therapy evaluation. The interim administrator indicated in the past, the facility had contacted the county and recommended emergency guardianship. The interim administrator confirmed the facility had contacted [MEDICAL CONDITION] for inpatient mental healthcare placement, but had not contacted the Staples facility for inpatient care as directed by P-A. The interim administrator indicated she did not feel the doctors looked at the mental health piece of R1's care needs. During interview on 1/15/19, at 8:50 a.m., P-B confirmed R1 had been admitted to the hospital with [REDACTED]. P-B confirmed R1 had not taken his medications 9 out of the last 10 days and had [MEDICAL CONDITION] activity while in the hospital. P-B indicated R1 continued to be aggressive with staff, and required four staff to help with cares at times. P-B indicated R1's medication need to be changed and needed placement in a inpatient mental healthcare unit. During interview on 1/15/19, at 9:02 a.m., LSW-C indicated she had asked if the facility had contacted the ombudsman regarding R1's continual refusals of care, safety concerns, family concerns with inpatient psychiatric care and DON told her she felt R1 was able to make his own decisions. LSW-C indicated she was not sure if R1 was able to make his own decisions and indicated she felt the facility should of stepped in before R1 got to this point. LSW-C indicated she felt R1's progressive mental and health decline, acute hospitalization could of been avoided if the facility had followed through with inpatient mental health placement when the health care provider had first written the order. During interview on 1/15/19 at 1:51 p.m., PA-A indicated he was aware R1 slowly got worse, was soiling himself and had skin breakdown. PA-A indicated he was aware R1 had an order for [REDACTED]. PA-A indicated he was aware several weeks had passed and the facility had still been working on trying to get guardianship for R1. PA-A indicated he felt if guardianship had been obtained sooner, R1's deterioration could have been avoided. PA-A indicated R1 recently had been sent to the local hospital for refusing cares and deteriorating health condition. Review of facility policy titled, Quality of Life undated, indicated the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. The policy indicated staff would document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. On 1/16/19, requested policy for providing cares, one was not provided.

Based on observation, interview and document review, the facility failed to implement individualized interventions and/or provide appropriate wound treatment in order to prevent the development of, and/or enhance the healing of, pressure ulcers for 1 of 3 residents (R41) in the sample reviewed for pressure ulcers. The facility's failure to implement individualized interventions resulted in actual harm for R41. Findings include: R41 currently had unstageable pressure ulcers on a right bunion, right heel and left hip and was not provided timely repositioning and offloading as directed by the care plan. R41 had not been provided assistance to reposition or offload for a total of 5 hours. In addition, the facility failed to implement floating of R41's heels consistently. On 10/21/15, R41 was continuously observed from 7:00 a.m. to 9:40 a.m. in bed asleep in a crooked body position. R41's trunk was twisted to his left side with his left hip and left buttocks were directly on the mattress, his legs were bent at the knee and facing left, his right foot was stacked on top of his left ankle. A 4 centimeter (cm) x 5 cm size scabbed, black area was visible to R41's right heel with the outermost part of the wound touching and pressing on the resident's left ankle. R41's right bunion wound was covered bit appeared to be pressing on his left outer foot. R41's left foot was directly on the mattress with the pillow displaced behind his calves and knees. The tip of the left heel was resting on the corner of the pillow. On 10/21/15, at 9:40 a.m. RN-C stated she was unaware R 41 had not been repositioned. She stated a staff member had called in this morning and they were struggling with staffing. RN-C observed and confirmed R 41 was lying on his left side with his left hip and buttocks directly on the bed, the bunion wound area stacked on top of his left foot, and the right heel wound resting on the inside of his left foot. RN-C confirmed R41's heels were not floated off the bed, and stated although staff try to float his heels, R 41 may have pulled the pillows out and up behind his knees. RN-C stated she would immediately assist R 41 to reposition. On 10/21/15, at 9:53 a.m. R 41 was lying partially on his left side, with LPN-D, LPN-H and NA-G present in the room. R 41's right bunion area ulcer was observed to be approximately 1.5 cm x 1.5 cm, raised, necrotic and the surrounding skin was red in color. R 41's right medial heel wound was observed to be covered by a dark scab approximately 4 cm x 5 cm. R 41 moaned in pain when LPN-D touched or moved his right foot. R 41 moaned, flinched, grimaced, clenched his jaw, squeezed his eyes shut and complained of pain while LPN-D applied [MEDICATION NAME] to the right bunion wound. LPN-D stated R 41 did not receive any medication prior to wound care that she knew of. R 41 jumped, flinched, furrowed his brows, squeezed his eyes shut, clenched his teeth and moaned in pain when LPN-D applied a [MEDICATION NAME] dressing to his right heel. LPN-H removed R 41's brief, and the resident's skin and brief were observed to be visibly soiled with stool. The border of the left hip ulcer was observed. The border was an irregular circle shaped area, with a tail pointing towards his torso, shiny, granulation tissue was noted. During the observation, R41's heels were resting directly on the bed until NA-G applied a rigid, plastic lined boot to R 41's right foot. NA-G indicated she would be assisting R 41 into a wheelchair at that time. At the time of this care, LPN-H stated R 41 received Tylenol for pain, but did not think R 41 was routinely pre-medicated before wound care or other cares. She stated overall, R 41 was pretty non-verbal, but did show facial expressions of pain, moaning and pulling away routinely. She stated R 41 always required 2 staff assistance with cares and they preferred to have 3 staff. NA-G stated R 41 had a history of [REDACTED]. LPN-H indicated R 41's buttocks ulcer was healed right now, but felt R 41 remained at very high risk for skin ulcers. On 10/21/15, at 1:59 p.m. LPN-D stated R 41 had really declined over the last few months. She stated she knew he was a challenge to get up in the morning, but wasn't sure how many staff if took to get him up. She stated he required staff assistance for repositioning. She stated normally she would check NA care sheets and monitor for repositioning and toileting but this morning she was busy and had not monitored. She stated the facility had a staff call in this morning and indicated she was unaware R 41 had not been checked on. LPN-D stated R 41 was to be repositioned every 2 hours, and that staff were expected to float his heels when in bed. On 10/21/15 2:25 p.m. NA-G and registered nurse (RN)-C both indicated they were unaware of the last time R 41 had been repositioned prior to the 9:53 a.m. care. A review of R 41's turning and repositioning worksheet for that day indicated that prior to 9:53 a.m., R41 had been repositioned at 4:40 a.m. This was confirmed by NA-G and RN-C. During the interview, NA-G stated R 41 had been on an every 2 hour repositioning schedule since admission to the facility. She stated she always tried to float all residents' heels, but didn't think she had been specifically told to float R 41's heels consistently. NA-G said she was not able to reposition R 41 on time this morning because they were short staffed. She stated someone had called in sick this morning and the facility had pulled an NA from R 41's unit. Consequently they'd only had 2 NAs to take care of 21 residents who were all on an every 2 hour repositioning and/or toileting programs, many of whom had behaviors, and required feeding and other assistance. NA-G stated staffing had been a problem for a long time, but had gotten really bad since August. On 10/21/15, at 2:27 p.m. registered nurse (RN-C) stated R 41 refused to lay on his right side and developed a pressure ulcer to his left hip because of this. She stated R 41 developed a pressure ulcer to his right bunion from swelling and pressure from his shoes. RN-C indicated R 41 used his right heel to self-propel himself in wheelchair and developed a blister to his right heel because of this. She stated she would expect staff to reposition R 41 every 2 hours as R 41 moved very little on his own. She stated there was no excuse for not repositioning him on time this morning. She confirmed R 41's care plan did not direct staff to float R 41's heels and stated she should have updated R 41's care plan and NA care sheets. She stated to float R 41's heels had been placed on the staff communication board, however, had not updated R 41's care plan. RN-C stated the usual facility protocol was to reposition all residents at least every 2 hours unless the resident's TTT indicated they required more frequent repositioning. On 10/21/15, at 3:06 p.m. LPN-H stated she had been working as a NA in the facility for awhile and worked both LPN and NA positions. She stated R 41 was supposed to be repositioned every 2 hours, and heels were supposed to be floated off the bed. She stated R 41 would get combative with cares and needed 3 people to complete his cares at times, but the facility only had 2 most of the time. She stated, He is a prime example of our staffing shortage. She stated he was not repositioned on time because they were not fully staffed. She stated the facility had 2 NA' s for 21 people, all on 2 hour repositioning schedules, and required 2 staff assist with transfers and toileting. She said if you do the math it doesn't add up. She stated it was really hard to make a resident wait because we don't have enough staff, but it's not safe to do cares with one staff like transfers with a lift, toileting, or repositioning either. R 41's admission Minimum Data Set ((MDS) dated [DATE], indicated R 41 had [DIAGNOSES REDACTED]. MDS identified R 41 had severe cognitive impairment, significant weight loss and required extensive assist with all activities of daily living (ADLs). The MDS also identified R 41 was always incontinent of bowel, had intact skin, and was at risk for developing pressure ulcers. R 41's admission pressure ulcer care area assessment (CAA) dated 3/18/15 identified R 41 had declined in ADL function, was incontinent of bowel and had advancing dementia. The CAA indicated R 41 never/rarely made decisions and was dependent on staff to anticipate all of his needs. The CAA further identified R 41's skin would be monitored daily during cares, assessed weekly during baths, and assessed using the Braden Scale and tissue tolerance tests (TTT) quarterly and as needed. R 41's quarterly MDS dated [DATE] indicated R 41 had severe cognitive impairment, required extensive assistance with all ADL's, was always incontinent of bowel, and had no weight loss. The MDS further identified R 41 had a current stage II pressure ulcer, was at risk for developing further pressure ulcers, and had a pressure reducing device on his bed and wheelchair. The MDS did not identify R 41 was on a turning and repositioning program. R 41's significant change MDS dated [DATE] identified R 41 had severe cognitive impairment, required extensive assistance with all ADLs. The MDS identified R 41 had 2 current stage II pressure ulcers and 1 unstageable pressure ulcer, and was at risk for developing further pressure ulcers The MDS did not identify R 41 was on a turning and repositioning schedule R 41's significant change CAA dated 10/19/15 indicated R 41 had an increase in dementia, required extensive assistance of 2 staff and a mechanical lift for all transfers, and had inadequate nutrition and signs of dehydration. The CAA further indicated R 41 required extensive assistance to move in bed, had current stage II and unstageable pressure ulcers on hip and feet, had pressure reducing mattress, gel cushion in wheelchair, and was to be repositioned per facility protocol. R 41's care plan dated 10/10/15, indicated R 41 was totally dependent on staff for locomotion, bed mobility, transfers and did not ambulate. R 41's care plan identified R 41 had current pressure ulcers to his right bunion, right heel and left hip, was at risk for developing further pressure ulcers and listed various interventions which included R 41 was able to tolerate a 2 hour repositioning program. R 41's care plan did not identify to float R 41's heels. Review of R 41's weekly skin integrity events, identified by the facility as comprehensive wound assessments revealed the following: -8/17/15 bruise to left gluteal fold and upper thigh, from catheter, catheter education was to be done for staff, inner right bunion area measured 0.7cm x 0.5cm, 1.5 cm in diameter, monitor. --8/30/15 left hip stage II pressure ulcer measured 6cm x 4cm with a 3cm x 1cm scab and right bunion area measured 1cm x 0.5cm. -9/16/15 right heel 4.5cmx3.5cm area with black circle surrounding it, mild to moderate pain, elevate, float heels, pain management, left hip 2cm x 1.5cm with a 3cm x 2.5cm bruise surrounding it, mild to moderate pain, left buttocks, 1.5cm x 1.5cm, stage I with white and pink tissue surrounding area, not open, hard lump underneath, mild to moderate pain. -9/18/15 right bunion 1 cm circular, unstageable, necrotic, 100% hard, paint with [MEDICATION NAME], elevate. Right heel, 2cm x 2cm blister, unable to assess wound bed, mild to moderate pain, weight loss, decreased food intake. A progress note dated 10/19/15 identified an error in documentation of location of R 41's pressure ulcers. The note identified the documentation dated 9/23/15. 9/30/15, 10/7/15, 10/14/15 as right hip pressure ulcer, should have been left hip pressure ulcer and 10/14/15 documentation of left heel, should of been right heel pressure ulcer. -9/23/15 right hip stage II 4.5cm x 2.5cm with 1.5cm x 2.0cm red center, R 41 had no pain, decreased food intake, and weight loss. Right heel stage II, 5cm x 4cm, no pain. Right bunion unstageable, 1cm x 1cm, necrotic, moderate pain at site. -9/30/15 right heel stage II, 4cm x 2cm, moderate pain, continued with decreased food intake and weight loss, right hip 2cm x 1cm with a 4.5cm x 2cm bruise around it, no pain. Right bunion 2cm x 1cm, unstageable, necrotic, moderate pain. -10/7/15 right heel stage II, necrotic, no pain, R 41 had decreased food intake and weight loss. Right bunion unstageable, necrotic, no pain, Left hip stage II, 2.5cm x 3cm with a 2.5cm tail, no pain. -10/14/15 right hip stage II, necrotic, 1.5cm x 2cm with a cm bruise-tail, no pain, decreased food intake and weight loss. Right heel, stage II, necrotic, mild pain, right bunion, unstageable, necrotic, mild pain at site. Review of R 41's Braden Scale for Prediction of Pressure Sore Risk forms dated 3/6/15, 6/11/15, and 9/16/15 revealed R 41 had been identified at risk for developing pressure ulcers due to limited mobility, occasionally moist skin and had a potential for friction and shear on all completed forms. Review of R 41's tissue tolerance tests (TTT) forms dated 6/13/15, 9/7/15, 9/10/15, 9/16/15 and 10/10/15 revealed for both lying and sitting positions R 41 had been identified to tolerate a 2 hour repositioning program. On 10/23/15, at 4:08 p.m. DON stated she would expect a comprehensive assessment, documented in the facility computerized system as a skin integrity event, each week for each pressure ulcer. She confirmed R 41's care plan included every 2 hour repositioning and indicated she would expect R 41's heels to be floated consistently. The facility's Skin Care Policy dated 8/24/09, indicated a resident who enters the facility without pressure sores does not develop pressure sores unless they are unavoidable; and a resident who has pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

Based on observation, interview and document review, the facility failed to consistently provide range of motion (ROM) services for 1 of 4 residents (R1) reviewed for ROM. Due to the deficient practice R1 sustained actual harm, a reduction in ROM and development of worsening contractures. Findings include: On 10/22/15, at 2:55 p.m. the facility's restorative nursing assistant (RA) was interviewed and stated R1 needed staff to provide ROM exercises 5 days a week to prevent stiffness. RA stated in the last few months R1 had become a lot tighter in the upper extremities on the right and left side. RA stated she was unable to spend the entire amount of time on exercises with R1 but stated she tried to squeeze 5 minutes of ROM in with R1 on the days when she (RA) was pulled to the floor so R1 wouldn't get tighter. The RA also stated when she was pulled to the floor to provide cares, she would still try to complete ROM for as many residents as she could between 2:30 p.m. and 4:30 p.m. She acknowledged she would not get the full repetitions in however, stated she documented on the rehab (rehabilitation) treatment logs so it may appear as though the 10 repetitions had been completed. RA also verified she had not reported R1's increased tightness/stiffness to anyone. On 10/22/15, at 5:04 p.m. nursing assistant (NA)-J stated she was unaware whether R1 was receiving ROM services but was aware R1 was stiffer in her arms at times. NA-J stated it was not the facility's usual practice for NAs to complete ROM services. NA-J stated restorative nursing usually completed ROM for all residents in the facility. At 5:06 p.m. NA-J was observed to provide passive range of motion (PROM) exercise to R1's right and left arms. R1's right arm was able to be moved just at shoulder height before R1 cried out in pain and NA-J stopped the movement. R1's left arm was able to be moved to less than shoulder height and NA-J stated R1 was too tight to continue the exercises on. NA-J confirmed R1 was tighter than normal. On 10/22/15, at 5:10 p.m. licensed practical nurse (LPN)-E stated R1 was stiffer in both arms in the last few months. LPN-E stated she had noticed R1 was stiffer when the restorative aid was unable to complete R1's ROM exercises due to being pulled to the floor to provide cares. LPN-E stated the RA would still try to do as many residents ROM as possible after working the floor, however the time was limited then and the RA was not able to complete the full exercise regimen. On 10/23/15, at 8:27 a.m. occupational therapist (OT)-A stated R1 had not had a recent occupational therapy evaluation for ROM exercises. OT-A stated she'd understood R1 recieved execrcises by restorative nursing, and stated she was unaware R1 had experienced a decline in ROM. On 10/23/15, at 8:54 a.m. OT-A was observed to complete an upper extremity ROM assessment to determine R1's functional ROM. OT-A assisted R1 to move the left arm at the shoulder, elbow, wrist and fingers. OT-A stated R1's left hand and wrist had limitations fixed at 20-25 degrees of extension. OT-A also stated R1's left hand fingers were limited and all fingers were noted to have contractures. OT-A then assisted R1 to move the right arm at the shoulder, elbow, wrist and fingers. OT-A stated R1's right arm had a contracture at the elbow with extension. OT-A also stated R1's right arm had limited motion in the supine position. During assessment of the right wrist and shoulder R1 stated ouch and the assessment was stopped. OT-A confirmed R1's assessment revealed a decline in ROM for both upper extremities since her previous OT assessment more than a year ago. On 10/23/15, at 1:44 p.m. during a follow up interview, RA stated her usual practice when a residents ROM changed, was to notify the nurse and therapy so they could complete an evaluation of the resident. RA confirmed R1 was stiffer in both upper extremities, especially when R1's ROM exercises were not done for 2 or more days. RA confirmed R1 had contractures and was aware she had gotten stiffer in the recent past. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had moderately impaired cognition and had [DIAGNOSES REDACTED].) The MDS also identified R1 needed total assistance of two staff with activities of daily living (ADL's) and had limited functional range of motion (ROM) to both upper and both lower extremities. R1's annual MDS dated [DATE], identified R1 needed total assistance with ADL's and had limited funtional ROM to both upper and lower extremities. R1's Communication Care Area Assessment (CAA) dated 1/30/15, identified R1 was able to be understood, had clear speech and did well when asked yes and no questions. R1's ADL's functional status/rehabilitation potential CAA dated 1/30/15, identified R1 was totally dependent on staff for all ADL's. R1's CAA did not address R1's functional limitation of ROM of all extremities and did not identify contractures. In addition, the CAA indicated a referral to other disciplines was not warranted and to continue the plan of care. R1's Nursing Rehab Observation dated 7/30/15, identified R1 had functional limitations in ROM to both the upper and lower extremities. The form did not address any changes of R1's ROM. R1's Nursing Rehab Observation dated 4/27/15, identified R1 had functional limitations in ROM to both the upper and lower extremities. The form did not address any changes of R1's ROM. R1's current care plan updated 8/6/15, revealed R1 was totally dependent on facility staff for bed mobility, transfers and locomotion. The care plan revealed R1 was non-ambulatory and was assisted to transfer with a total body mechanical lift. The care plan directed facility staff to complete the restorative nursing program as indicated. R1's care plan did not identify R1's functional limitation of ROM of all extremities and did not address interventions for contractures. Review of R1's current physician orders [REDACTED]. Review of R1's monthly treatment records, order for nursing restorative program, once a day Mon, Tue, Wed, Thu, Fri 3-5 times per week as scheduled by rehab staff from to 9/30/15 revealed the following: 10/1/15 to 10/22/15, the treatment record documentation revealed no documentation of R1's ROM services had been provided 16 out of the 16 days. -9/1/15 to 9/30/15, the treatment record revealed no documentation of R1's ROM services had been provided 16 out of the 21 days. -8/1/15 to 8/31/15, the treatment record revealed no documentation of R1's ROM services had been provided 21 out of the 21 days. -7/1/15 to 7/31/15, the treatment record revealed no documentation of R1's ROM services had been provided 2 out of the 23 days. Review of R1's restorative nursing program logs for R1 to receive ROM to both upper and lower extremities for 10 repetitions, from May 2015, to October 2015, revealed the following: -May 2015, documentation indicated R1 did not receive ROM services for 5 out of 21 days. No further documentation was noted on the logs. -June 2015, documentation indicated R1 did not receive ROM services for 2 out of 22 days. No further documentation was noted on the logs. -July 2015, documentation indicated R1 did not receive ROM services for 2 out of 23 days. No further documentation was noted on the logs. -August 2015, documentation indicated R1 had recieved ROM services 21 out of 21 days. No further documentation was noted on the logs. -September 2015, documentation indicated R1 had received ROM services for 22 out of 22 days. No further documentation was noted on the logs. -October 2015, documentation revealed R 1 did not receive ROM services 2 out of 16 days. The documenation also revealed R1's right side was more stiff both upper and lower extremity. Review of R1's nursing to rehabilitation notification change in functional status/order forms revealed the following; -9/8/15, screening requested to check left hand brace, and fingertips. OT educated staff on correct application of day finger/digit seperator and indicated no further OT needed at this time. -8/7/15, screening requested for blister/ulcer to R1's left heel. OT determined sheep skin in foot pedals and dycem under the sheep skin appropriate to keep in place. -6/3/15, screening requested to replace R1's left hand brace, OT completed screening, and identified R1's case manager had reported the brace missing for a while. OT located the brace and presented it to the case manager, no further services provided. The forms lacked information of R1's increased stiffness to right and left upper extremities. In addition, the forms did not indicate a change in R1's restorative nursing program. On 10/23/15, at 2:02 p.m. registered nurse (RN)-B denied R1 had contractures in any of her extremities and indicated the facility only had one resident with a contracture at present. RN-B further stated if a resident had a decline or a loss in ROM, the physician would be notified to see if a referral to therapy would be appropriate. RN-B was unaware R1 had any loss or decline in ROM. RN-B stated she was aware R1 was getting restorative nursing services for ROM exercises to all extremities, but was unaware if R1 had received the full exercise program. RN-B stated she would expect R1 to receive full ROM exercises to all extremities according the restorative nursing program. On 10/23/15, at 2:09 p.m. NA- G stated she was aware R1 was a lot stiffer in the upper arms when assisting R1 with dressing. NA-G stated R1 wore a brace to the left arm at night and brace on both feet during the day. NA-G stated restorative nursing was responsible for completing R1's ROM exercises. NA-G stated if the restorative aid was working on the floor then residents would not get their exercises. On 10/23/15, at 3:30 p.m. NA-A stated R1's arms were stiffer when dressing and undressing in the last few months. She stated R1 recieved restorative nursing exercises when the RA was available to complete the restorative nursing program. NA-A stated she was aware R1 had become stiffer in the last few months NA-A stated R1 received restorative nursing exercises when the restorative aid was not working on the floor. On 10/23/15, at 4:19 p.m. the director of nursing (DON) stated she was the RN responsible to oversee the facilities restorative nursing program. The DON confirmed the RA had been pulled from restorative nursing frequently to provide residents cares because the facility was short staffed. She indicated restorative services and ROM services were not being provided to all residents in the facility consistently. The DON stated the administrator was aware restorative services and ROM services were not being provided to all residents in the facility consistently. The DON stated she was not aware R1 had a decline in ROM and was unaware R1 had contractures. A facility policy titled, Rehabilitative Nursing Care revised 2/18/13, revealed rehabilitative nursing care was provided to each resident who was admitted . The policy directed facility staff to provide rehabilitative nursing care to be performed daily for those residents who required those services. The policy indicated the program was to include assisting residents to carry out prescribed therapy exercises and assisting residents with their range of motion exercises. An undated facility policy titled Range of Motion Exercises, identified steps to complete ROM exercises for residents. The policy directed facility staff to report any changes in ROM to the charge nurse and indicated the ROM exercises should be documented in the resident's medical record with the following information; date and time performed, name and title of person who performed the service, what type of ROM, whether the exercises were active or passive, how long the exercise was conducted, if and how long the resident participated in the procedure, any changes in the resident's ability to participate, any problems or complaints made by the resident and if the resident refused and why.

Based on observation, interview and document review the facility failed to provide ambulation services to prevent loss of function for 1 of 2 residents (R39) who required assistance with ambulation. R39 was not provided assistance with ambulation and was not re-assessed upon a decline in ambulation. R39's decline in the ability to ambulate resulted in actual harm. Findings include: On 10/19/15, at 5:46 p.m., R39 was seated in a wheelchair in her room. R39 stated staff were unable to assist her with walking because they didn't have enough staff. R39 stated the staff had stopped walking her at least a month ago and stated she wasn't sure whether she could walk any more. R39 further stated she hated to lose the ability to walk. On 10/20/15, at 11:32 a.m. R39 was observed seated in a wheelchair, propelling self to the dining area. At 2:30 p.m. R39 was observed seated in a wheelchair outside talking with other residents. R39 was not observed to ambulate throughout the day. On 10/21/15, at 7:30 a.m. R39 was assisted to transfer out of bed by nursing assistants (NA)-I and NA-A with the use of a PAL lift (a mechanical lift device). R39 independently applied and attached the sling to the hooks of the lift. NA-I operated the lift while NA-A provided guidance and assisted her into a standing position. The NAs proceeded to wheel R39 in the PAL lift into the bathroom. NA-I lowered R39 onto the toilet with the PAL lift. NA-A handed clothing and hygiene supplies to R39 to independently complete her morning cares. On 10/21/15, at 9:00 a.m. R39 was observed seated in a wheelchair propelling herself back form the dining area. At 11:30 a.m. R39 was observed seated in a wheelchair outside visiting with other residents. R39 was not observed to ambulate throughout the day. On 10/22/15, at 1:00 p.m. R39 was observed seated in a wheelchair outside visiting. At 5:32 p.m. R39 was observed seated in a wheelchair sitting at a table in the dining room. At 6:00 p.m. R 39 was seated in a wheelchair and propelled herself back to her room. R39 was not observed to ambulate throughout the day. On 10/21/15, at 8:14 a.m. NA-I was interviewed and stated R39 used to be able to transfer with assistance of one staff with a gait belt and used to use the walker to walk into the bathroom. NA-I said R39 used to walk with staff assistance and the walker but was no longer able to. NA-I stated R39 had loved to walk and that she knew R39 missed walking. NA-I was unsure when R39 had become unable to walk and was not sure why. On 10/21/15, at 3:15 p.m. the facility 's restorative nursing assistant (RA) stated she had been taken out of the restorative aid role to work on the floor to provide direct care. RA said this happened quite a bit and as a result she'd been unable to complete R39's daily ambulation program. RA stated she was aware R39 's ability to ambulate had declined and said she felt bad about not being able to assist R39 with her ambulation. RA also stated she'd noticed R39 would have difficulty standing when she hadn't been walked for a few days in a row. RA indicated the code of NS on the restorative therapy logs represented no shows for the days RA was pulled to the floor and therefore unable to complete R39's ambulation program. On 10/22/15, at 10:10 a.m. during a follow up interview, R39 stated there had been changes in her ability to ambulate and that her legs had become weaker. R39 denied any illness or injury which might have affected her ability to ambulate. R39 stated at times her legs were weak due to low potassium, however she reported taking potassium supplements which had been effective. She stated that when she was unable to have assistance with walking her legs became weaker. R39 stated she felt bad for the staff because they were so busy and there weren't enough of them. She also stated at present, she was unsure if she would be able to walk if someone tried to help her. R39 also stated she would feel bad if another resident was unable to exercise because staff was exercising with her. She stated she used to be able to walk over 100 feet with her walker and staff assistance but that her walking exercises had ended about a month ago. R39's quarterly Minimum Data Set ((MDS) dated [DATE], identified R39 was cognitively intact and identified [DIAGNOSES REDACTED]. The MDS also identified R39 needed extensive assistance from staff for transfers and ambulation. A review of prior quarterly MDS assessments, conducted 3/11/15 and 6/11/15, indicated R39 had required extensive assistance for transfers, but had needed limited physical assistance from staff for ambulation. R39's activity of daily living (ADL)/functional status rehabilitation potential Care Area Assessment (CAA) dated 3/11/15, indicated R39 was cognitively intact, needed extensive assistance of one staff for transfers and ambulated in the room and hallway with extensive assistance of one staff and the use of a walker. The CAA further identified R39 had used a wheelchair with limited physical assistance from staff for locomotion on and off the unit. R39's current care plan updated 9/15/15, indicated she needed extensive assist of one staff for ambulation. The care plan also indicated R39 required extensive assistance for transfers. The care plan interventions directed facility staff to complete a restorative nursing program as indicated. R39's current physician orders [REDACTED]. In addition, another order directed staff to ambulate R39 with a 4 wheeled walker (WW) with assistance of one, to/from the bathroom and in room transfers twice a day. R39's restorative treatment log records were reviewed and revealed the following: In October 2015, there was no documentation for 15 out of 15 week days to indicate implementation of R39's ambulation program. This flow sheet indicated ambulation was done as needed (PRN.) In September 2015, R39's order for ambulation twice a day in room had been completed once a day for 8 of 30 days. R39 had received assistance with ambulating 100 feet on 9 out of 22 week days. The log indicated R39 had last received ambulation per her restorative plan on 9/10/15. The log was coded as NS for 10 of the 22 week days. In August 2015, R39's order for ambulation twice a day in room had been completed once a day for 8 out of 31 days. R39 had received assistance with ambulating 100 feet on 18 out of 21 week days. The log was coded as NS for 3 of the 21 week days. In July 2015, R39's order for ambulation twice a day in room had been completed once a day for 14 of 31 days. In addition, the logs indicated R39 received assistance with ambulating 100 feet on 19 of 23 weekdays days. The log was coded as NS on 4 days. In June 2015, R39 received assistance with ambulating 100 feet on 5 of 22 days. The log was coded as NS on 17 days. In May of 2015, R39 received assistance with ambulating 100 feet on 12 of 21 days. The log was coded as NS for 9 other days. Nursing progress notes were reviewed from 8/1/15 to 10/23/15, and revealed the following: On 8/24/15, R39 had been educated on needing two staff assist with transfers due to R39 requesting one staff assist. On 9/6/15, R39 needed extensive assistance of two staff for transfers with a PAL lift. On 10/17/15, R39 was unable to ambulate daily related to increased weakness in legs, ambulation was changed to as tolerates. The note also revealed staff were to encourage R39 to ambulate when able. The progress notes lacked further documentation regarding R39's progress in the restorative nursing program for ambulation, and lacked any further description of R39's ambulation ability. Review of R39's care conference reports for June 2015 and September 2015, revealed the following: 6/18/15, R39 ambulated daily with assist of one staff with use of a walker. The notes revealed R39 was doing well with ambulation and had been taking potassium supplements daily for [DIAGNOSES REDACTED] which had been effective. 9/15/15, R39 ambulated daily with assist of one staff with use of a walker and needed assistance with a mechanical PAL lift as needed for transfers. The note lacked assessment of of R39's restorative nursing program or any changes in the resident's ability to ambulate. On 10/22/15, at 3:13 p.m. registered nurse (RN)-B confirmed R39 had declined in ability to ambulate. RN-B stated she was unsure whether the decline was related to not getting restorative therapy consistently, or because her legs were weaker. RN-B confirmed R39 began needing assistance with a mechanical lift for transfers about a month ago. She verified R39 had been able to pivot transfer with one NA previously and that R39's decline in ambulation occurred at least a month ago. RN-B confirmed any decline in a resident's exercise could affect their overall ability. RN-B verified the RA was often pulled from restorative therapy to work as an aid on the floor. On 10/22/15, at 5:23 p.m. licensed practical nurse (LPN)-E stated she did not feel safe ambulating R39 at that time. LPN-E indicated R39 had not ambulated in multiple weeks and LPN-E refused to ambulate R39 at the present time. On 10/23/15, at 8:41 a.m. RN-B confirmed R39 had an active order for restorative nursing program to ambulate 3-5 times a week on week days, and confirmed R39's care plan directed facility staff to complete the restorative nursing program as indicated. RN-B stated she would expect R39's care plan to be followed. On 10/23/15, at 9:37 a.m. the director of nursing (DON) stated R39 had originally been referred for therapy on 3/25/15. That referral indicated staff were to provide restorative therapy for 2 weeks and then R39 was to have been re-evaluated by therapy. The DON stated R39 had not been re-evaluated by therapy following the order on 3/25/15, and was unsure why. The DON confirmed R39 had not currently been receiving restorative therapy as ordered, 3-5 times a week (on week days). The DON also stated monthly treatment records would document ambulation provided by the NA's. When reviewed, the DON confirmed the lack of documentation on the treatment records and verified the NS codes on R39's restorative logs would indicate R39 had not been assisted with ambulation. During additional interview with the DON on 10/23/15, at 4:19 p.m. she stated she was the RN responsible for the restorative nursing program. The DON stated she was aware the RA was routinely pulled to the floor when they were short staffed and confirmed restorative services were not being provided consistently to the residents. The DON stated the administrator was also aware the RA was being pulled from restorative services and was aware restorative services were not being consistently provided to residents. A facility policy titled, Rehabilitative Nursing Care revised 2/18/13, revealed rehabilitative nursing care was provided to each resident that was admitted . The policy directed facility staff that rehabilitative nursing care was to be performed daily for those residents who required service. The program was to include assisting residents to carry out prescribed therapy exercises and assisting residents with their range of motion exercises.

Based on observation, interview and document review, the facility failed to reassess, develop and implement interventions to prevent the development of, or promote healing of, pressure ulcers for 1 of 1 resident (R6) reviewed who had current pressure ulcers. This resulted in actual harm for R6 who acquired two pressure ulcers while in the facility, one of which progressed to a Stage 3 pressure ulcer, (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Findings include: Although R6 had developed a pressure ulcer to the coccyx on 5/10/14, and had subsequently developed another pressure ulcer on the heel, the facility did not reassess, or implement interventions to prevent further skin breakdown, which caused actual harm for R6. R6's significant change Minimum Data Set ((MDS) dated [DATE], identified R6 had [DIAGNOSES REDACTED]. The MDS identified R6 had severe cognitive impairment, required extensive assistance with bed mobility, transferring, toileting, did not ambulate and was incontinent of bowel and bladder. Further, the MDS identified R6 was at risk of development of pressure ulcers, but did not have any pressure ulcers at that time. Review of R6's Care Area Assessment (CAA) dated 5/4/14, identified R6 transferred with use of a mechanical lift and assist of two staff, seldom moved in chair or bed, was at moderate risk for pressure ulcer development due to diagnosis, ulcers present at this time, immobility, medication, [MEDICAL CONDITION], incontinence and poor nutrition. The CAA identified R6 had an alternating pressure mattress (APM) on the bed and a pressure reducing cushion in wheelchair. Although the CAA identified an ulcer, the MDS only identified R6 as at risk. Review of the facility's form, Minnewaska Lutheran Home Tissue Tolerance Testing dated 3/14/14, identified for both sitting in a chair and lying, R6 could tolerate a 2 hour repositioning program and "reposition every 2 hours" as interventions. No further pressure distribution assessment was provided. Even though R6 had developed a pressure ulcer after 3/14/14, no reassessment had been done to determine whether the every 2 hour repositioning schedule was still appropriate for R6. R6's care plan revised on 5/15/14, identified R6 had a stage 3, pressure ulcer on the coccyx, a blister on the right heel, and areas on the left foot. The care plan interventions indicated that R6 required extensive assistance of 2 staff for bed mobility, extensive assistance with transfers, and a mechanical standing lift. The care plan also included interventions for a pressure reduction device in chair, APM on bed, to encourage repositioning every two hours as needed, to follow wound protocol as needed, to complete a "Tissue Tolerance test quarterly and as needed," and to notify physician of significant changes in the skin integrity. Review of a clinical record note dated 5/10/14, identified R6 had developed a "new ulcer" on the coccyx, identified as a stage 3 pressure ulcer. According to the documentation, the pressure ulcer measured 3 centimeters (cm) by 1.5 cm with a scant amount of clear drainage, and had 50% yellow sough and 50% pink granulation tissue in the wound bed. The note identified the area was washed with wound cleanser and covered with an Allevyn dressing. The dressing was to be changed every five days. The note also indicated R6 "has APM mattress." Review of the facility's, Minnewaska Lutheran Home Physician Communication form dated 5/10/14, revealed R6 had been identified with a blister/eschar on right heel, and an open area on the coccyx. The communication form indicated facility staff had requested orders for application of [MEDICATION NAME] solution to the blister on the heel followed by an Allevyn dressing and blue foam boot, and an Allevyn dressing to the coccyx area. Review of the clinical record note dated 5/28/14 identified R6 had developed a large dark brown/black fluid filled area DTI (deep tissue injury) on the right heel measuring 4.4 cm by 4 cm. The note indicated the fluid filled area had drained, was dry and had 100% stable black eschar. The note also indicated the surrounding tissue was pink and soft with dry dead skin from where the previous blister had been, and indicated a blue foam boot was to be worn for protection at all times with heels floated while in the recliner and bed. The note identified a stage 3 pressure ulcer remained on the coccyx with a small amount of serosanguinous (thin,bloody) drainage, measured 0.5 cm by 0.7 cm, which showed slow improvement. During observations on 6/4/14, from 7:10 a.m. until 10:06 a.m. R6 was observed at 7:10 a.m. seated in a wheel chair, with a blue quilted heel boot on the right foot, resting on the foot pedal of the wheel chair. At 8:27 a.m. R6 was observed to remain seated in the wheel chair with the right foot in the same position on the foot pedal as he ate the breakfast meal in the dining room. At 9:00 a.m. a family member approached R6 in the dining room, wheeled him towards his room, entered briefly and then proceeded to assist R6 outside the front entrance of the facility. At 9:05 a.m. R6 was observed outside near the entrance to the facility, seated in the wheelchair with his feet resting on the wheelchair pedals. R6's wife was seated near R6, at the entrance to the facility. R6 was observed to remain in the same position until 10:06 a.m., when R6 was assisted to his room and to be repositioned. R6 was observed to have remained in the same position for 2 hours and 56 minutes, without having been offered or encouraged to change positions. During an interview on 6/4/14, at 9:53 a.m. nursing assistant (NA)-B confirmed R6 had been assisted into the wheel chair at approximately 7:00 a.m. and had not been offered and/or assisted to be repositioned since. NA-B confirmed the care plan directed R6 to be repositioned every 2 hours and further stated "but we try to get to him sooner." Following the interview with NA-B, R6 was assisted from the wheel chair with a mechanical standing lift at 10:06 a.m. with assistance of NA-B and NA-A. During an interview on 6/4/14, at 10:10 a.m. registered nurse (RN)-A confirmed R6's current care plan directed staff to follow a two hour repositioning schedule and that R6 had current pressure ulcers. RN-A confirmed the expectation of staff was to follow the care plan at all times, including when a resident sat outside the facility. During an observation with RN-B on 6/4/14 at 1:08 p.m., R6 was observed to have an unstageable pressure ulcer on the right heel and pressure ulcers on the coccyx. The heel area was observed to have black eschar, and measured 3.9 centimeters (cm) by 3.6 cm. The coccyx area had an Allevyn dressing (an adhesive foam dressing) in place, however the entire coccyx area was dusky pink in color. The open area on the coccyx measured 0.1 cm by 0.3 cm. RN-B verified R6 had 2 pressure ulcers, one on the coccyx and an unstageable ulcer on the right heel. RN-B confirmed a new intervention had been put in place including use of a larger Allevyn dressing to cover the entire area of the coccyx in an attempt to prevent further pressure ulcers. During an interview on 6/4/14, at 1:21 p.m. the hospice RN confirmed R6 had a current pressure ulcer and indicated it was concerning that R6 had not been repositioned for approximately 3 hours. During an interview on 6/5/14, at 9:20 a.m. the director of nursing (DON) confirmed R6's current care plan and also confirmed staff were directed to follow the care plan for resident cares. The facility policy titled Skin Care policy, revised 8/24/09, was reviewed. The policy indicated a comprehensive assessment would be completed routinely (admission, quarterly, significant change), and as needed. The policy indicated an assessment would include the identification of risk factors, risk assessment tools of a Braden Scale (tool for predicting the development of pressure ulcers), and a Tissue Tolerance Assessment (tool to evaluate the need for redistribution of pressure). The policy indicated analysis of the comprehensive assessment would include the development of individualized interventions for residents. The facility procedure titled Prevention of Pressure Ulcers revised 4/5/13, was reviewed. The procedure indicated the usual cause of pressure ulcers as, "when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area which destroys the tissues." The procedure also identified the most common site of a pressure ulcer as where the bone is near the surface of the body, and listed various locations which included the backbone and heels. The procedure directed preventative actions which included routine skin care and "change position at least every 2 hours."